HospitalInspections.org

Based on observation and staff interview, the facility failed to separate use areas from corridors by smoke resisting partitions. This condition had the potential to allow smoke to migrate into the exit corridor. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/29/11, at 11:14 am revealed a hole around a pipe above ceiling at Room 622 on the 6th Floor.
In an interview conducted at the time of observation, (11/29/11, at 11:14 am), Engineering C acknowledged the corridor wall penetration.

Based on observation and staff interview, the facility failed to separate use areas from corridors by smoke resisting partitions. This condition had the potential to allow smoke to migrate into the exit corridor. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/30/11, from 10:59 am to 1:58 pm revealed:
1. The temporary 1st Floor Cardio Staff Office wall failed to extend to the deck above the suspended ceiling.
2. Above ceiling at the 1st Floor Double Doors near Room 1035 Director of Diagnostic Imaging revealed a penetration in the corridor wall.
3. On the Ground Level above ceiling at the Director of Pharmacy Office revealed a penetration around a 6 inch sprinkler main in the corridor wall.
In an interview conducted at the time of observation, (11/30/11, from 10:59 am to 1:58 pm), Engineering C acknowledged the corridor wall penetrations.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 2:01 pm on the 2nd Floor revealed a wood door chock holding open the Nursery Door 2210.
During an interview on 11-29-11 at 2:01 pm, Engineering B confirmed the chock holding open the door and removed it immediately.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:57 am revealed a metal coat rack holding open the door to the 5th floor visitor waiting room.
During an interview on 11-29-11 at 9:57 am, Engineering B confirmed the coat rack in front of the door and removed it immediately.



27395

Observations during the facility tour on 11/29/11, from 9:35 am to 11/30/11 at 3:25 pm revealed:
1. The 7th Floor Conference Room 700 Door had four pencil size holes that penetrated the door.
2. The Ground Level Vending Machine Room Door failed to latch when swung shut by the automatic closure.
3. The Ground Level Telephone Closet by the South Addition failed to have positive latching hardware installed in the door.
4. The 1st Floor PACU Bay 13 sliding door failed to latch when pulled shut.
In an interview conducted at the times of observation, (11/29/11, from 9:35 am to 11/30/11 at 3:25 pm), Engineering C acknowledged the findings.

Based on observation and interview, the facility failed to maintain the vertical opening which provides a minimum 1-hour fire rating. This deficient practice affected all patients, staff and visitors using the North Stair Tower. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:28 am revealed the door on the 5th floor North stair tower failed to close and latch, due to air pressure within the stair enclosure.
During an interview on 11-29-11 at 9:29 am, Engineering B confirmed the North stair tower door on the 5th floor failed to latch within the door frame.

Based on observation and interview, the facility failed to maintain the vertical opening which provides a minimum 1-hour fire rating. This deficient practice had the potential to allow fire to penetrate floor openings more quickly. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-28-11, from 3:26 pm to 11-30-11 at 9:46 am revealed:
1. Inside the 7th Floor East Corridor North Wire Closet, conduits were removed, which left a penetration through the floor assembly.
2. Inside the 3rd Floor East Corridor 2nd Wire Closet, two conduits were removed, which left a penetration through the floor assembly to the 2nd Floor.
3. Inside the 3rd Floor East Corridor North Wire Closet, conduits were removed, which left a penetration through the floor assembly.
4. The 1st Floor Northeast Exit Stairwell to the MSB Link failed to maintain 1-hour fire separation throughout the stairwell. A sliding glass door on the first floor that separated the Hospital from the Stairwell failed to meet the required 1-hour fire separation.
During an interview on (11-28-11, from 3:26 pm to 11-30-11 at 9:46 am), Engineering C confirmed the penetrations in the vertical separations.

Actual NFPA Standard:
NFPA 101, 19.3.1 Protection of Vertical Openings.
19.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

Based on observation and interview, the facility failed to ensure that 2 of 2 sets smoke separation doors are capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread throughout the 4th floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 11:37 am and 1:05 pm revealed:
1. The space between the smoke doors next to Room 427 was greater than 1/8 inch.
2. The space between the smoke doors next to Conference Room 4411 was greater than 1/8 inch.
During an interview on 11-29-11 at 11:37 am and 1:05 pm, Engineering B confirmed the space between the doors were greater than 1/8 inch.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 18.3.7.6*.

Based on observation and interview, the facility failed to ensure that a smoke separation door is capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread throughout the Ground Level. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11/30/11, at 3:19 pm revealed the Ground Level Double Doors by OR 5 failed to latch when swung shut.
During an interview on (11/30/11 at 3:19 pm), Engineering C confirmed the doors failed to latch.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential to spread into the egress corridors. Facility census was 52 of 173.

Findings are:
Observations on 11-29-11 from 9:45 am to 2:54 pm revealed:
5th Floor:
1. Telephone closet door on the 5th floor failed to provide latching device, only a dead bolt lock.
2. Staff only/Break room on the 5th floor across from room 502 failed to latch within the door frame.
3. Electrical closet door on the east side of building across from room 505 failed to provide latching device, only a dead bolt lock.
4. Electrical chase door on the 5th floor failed to provide latching device, only a dead bolt lock.
5. Wire closet door across from Therapy/Gym on the 5th floor failed to provide latching device, only a dead bolt lock.
Ground Floor:
6. Purchasing door next to the small storage room in the Ground floor failed to close and latch within door frame.
During an interview on 11-29-11 at times of observations, Engineering B confirmed all the findings.



27395

Findings are:
Observations during the facility tour on 11/29/11, from 10:52 am to 11/30/11, at 3:12 pm revealed:
1. Holes around cables and conduits on the 7th Floor above ceiling in the North Soiled Utility Room.
2. All 3rd Floor Electrical and Phone Closet Doors failed to have positive latching hardware installed in the doors.
3. The automatic closure failed to be installed on the 1st Floor Histology Lab South Door. The automatic closure had been removed on the day of the survey.
4. The 1st Floor Radiology Room west of the Flouro Room measured over 50 square feet with combustible storage inside. The facility failed to install an automatic closure on the room door.
5. The 1st Floor Hot Lab, which was used for the storage of radioactive material, failed to have an automatic closure installed on the door. A louver installed in the Hot Lab Wall opened the room to the Nuclear Medication Room 2, which is a patient care area. The facility failed to seal the louver with smoke resisting partitions.
6. The Ground Level Kitchen Storage Room failed to have positive latching hardware installed in the door.
7. The Ground Level Morgue Elevator Equipment Room failed to latch when swung shut. A metal plate was attached over the latch, which allowed the door to close without latching.
In an interview conducted at the time of observation, (11/29 am, from 10:52 am to 11/30/11, at 3:12 pm), Engineering C acknowledged the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential to spread into the egress corridors. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/29/11, from 9:27 am to 1:05 pm revealed:
1. The 7th Floor North Storage Room Double Doors failed to latch when swung shut.
2. Above Ceiling on the 6th Floor above Soiled Utility 6016 revealed a penetration in the corridor wall.
3. The Double Doors failed to latch when swung shut to the 1st Floor Shell Space east of the North Elevator used as storage.
In an interview conducted at the time of observation, (11/29/11, from 9:27 am to 1:05 pm), Engineering D acknowledged that the doors failed to latch.

Based on observation and staff interview, the facility failed to provide a smoke resisting partition to separate the Gift Shop from the corridor. This condition had the potential to allow smoke and fire to migrate from the Gift Shop to the exit corridor. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/28/11, at 12:54 pm revealed the Gift Shop Sliding Glass Doors failed to have positive latching hardware installed in the doors. The Gift Shop exceeded 500 square feet to meet the exception to allow it to be open to the corridor.
In an interview conducted at the time of observation, (11/28/11, at 12:54 pm), Engineering C acknowledged the square footage of the Gift Shop, and that no positive latching hardware was installed in the doors.

Based on observation and staff interview, the facility failed to maintain stairwell enclosure doors so that they latched when closed. This condition had the potential to allow smoke or fire to migrate into the exit enclosures. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/28/11, from 2:04 pm to 2:16 pm revealed:
1. The East Staircase, 2nd Floor Door failed to latch when closed.
2. The West Staircase, 2nd Floor Door failed to latch when closed.
In an interview conducted at the times of observation, (11/28/11, from 2:04 pm to 2:16 pm), Engineering C acknowledged that the doors failed to latch.

Based on observation and staff interview, the facility failed to provide a new stair tower that only allowed access into the stair tower from normally occupied areas. This condition had the potential to allow smoke and fire directly into the stair tower from a mechanical room. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/29/11, at 9:25 am, revealed the New North Stair Tower 9th Floor Elevator Equipment Room opened directly into the stair tower. The facility failed to prohibit the room from entering directly into the stair tower.
In an interview conducted at the time of observation, (11/29/11, at 9:25 am), Maintenance C confirmed that the mechanical room opened directly into the stair tower.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1 (d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Based on observation and staff interview, the facility failed to provide a locked egress device that would release with the activation of the fire alarm. This deficient practice affects all patients, staff and visitors on the seventh floor of the building that may need to evacuate the building. The facility census was 52.
Findings are:
During the fire alarm testing on 11/29/11 from approximately 3:55 pm through 4:30 pm revealed the failure of the magnetic locks on the two north exits from releasing during the fire alarm testing. Interview with Engineering C at this time confirmed the failure of the two exit doors from releasing during the fire alarm testing.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1
NFPA Standard: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2000 NFPA 101, 19.2.2.2.4

Based on observation and staff interview, the facility failed to maintain a horizontal exit door in accordance with the National Fire Protection, 101. This condition had the potential to allow the doors to swing open during a fire due to the superheated gases from the fire conditions, spreading smoke and fire throughout the exit corridors. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/30/11, 2:01 pm revealed the 3-hour fire rated doors in the ER Department failed to latch when swung shut.
In an interview conducted at the time of observation, (11/30/11, 2:01 pm), Engineering A acknowledged that the doors failed to latch.

Based on observation and interview, the facility failed to provide an exit sign to indicate the continuous path of egress on the second floor. This deficient practice affected all staff and visitors in an emergency situation on the first floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 4:20 pm revealed the exit sign outside the Ground Level construction area for the new oxygen storage room was obstructed by white plastic film used by the contractors.
During an interview on 11-29-11 at 4:20 pm, Engineering B confirmed the white plastic obstructed the exit sign and stated the sign was not visible.

Based on documentation review and interviews the facility failed to conduct fire drills to include all staff and occupants. In addition the facility failed to include the activation of the fire alarm during the hours of 6:00 am through 9:00 pm or a coded announcement during the hours of 9:00 pm through 6:00 am. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. The facility census was 52.

Findings are:
1. Interview with Engineering C on 11/29/11 at between 1:00 pm and 4:00 pm revealed the fire drills conducted at the hospital did not include the entire building as they would walk up to an area and give them a fire scenario. Only the staff in the immediate area would participate. When asked about who was participating in the drills a complete list of all employees working on that day was offered but who had actually participated could not be identified.
2. Documentation review of the fire alarm activation report and the fire drills reports, on 11/29/11, 12/1/11, and 12/5/11 revealed the fire alarm was not activated for all the fire drills conducted during the Day shift and Evening shift fire drills. Documentation for the fire drills conducted indicated the fire alarm had been sounded but could not be verified on the fire alarm activation report. In addition many of the drill forms had the " Did PBX operator report Code Red over intercom/radio? " as NA or not marked at all.
3. Many fire drill reports were incomplete and did not contain the year of the drill just the month and day. In addition all questions were not completed on all the forms.
4. Fire drills conducted in the Surgery were paper drills and not fire evacuation drills including physicians and surgeons.
5. Laboratory quarterly fire drill documentation could not be provided.
Interview with Engineering C at this time confirmed the findings.
NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2
NFPA Standard:
(a) Hazard Assessment.
1. An evaluation shall be made of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment.
2. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.
(b) Fire Prevention Procedures. Fire prevention procedures shall be established.
(c) Emergency Procedures.
1. Procedures for operating room/surgical suite emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the operating room including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
2. Emergency procedures shall be established for controlling chemical spills.
3. Emergency procedures shall be established for extinguishing drapery, clothing, or equipment fires.
(d) Orientation and Training.
1. New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use. 1999 NFPA 99 12-4.1.2.10
2. Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.
3. Fire exit drills shall be conducted periodically.
NFPA Standard: Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually. 1999 NFPA 99 10-2.1.4.3

Based on observation and interview, the facility failed to assure that the fire alarm system is installed, maintained and assure that the fire alarm system is installed and maintained in accordance with NFPA 72. This requires audible and visual devices in all common use areas. This deficient practice affected all staff, and visitors in the Laboratory area. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 4:17 pm and 4:19 pm during a fire alarm test revealed:
1. The facility failed to provide an audible and visual device in the laboratory break room.
2. The facility failed to provide an audible and visual device in the laboratory mail/coat/dressing room.
3. White plastic film covering a visual and audible fire alarm device in front of the construction of the new oxygen storage room on the first floor.
During an interview at 11-29-11 at each time of observations, Engineering B confirmed the lack of fire alarm devices in the common use areas.

Based on observation and staff interview, the facility failed to install the fire alarm in accordance with the National Fire Protection Association, 72. These conditions had the potential to not alert occupants of a fire and prevent affective evacuation. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/29/11, from 3:54 pm to 4:20 pm revealed:
1. The facility-wide voice evacuation message failed to notify occupants to evacuate the facility. The message did not give any instruction other than to stay by the speakers and stand by.
2. A fire alarm strobe failed to be installed on the south side of both sets of smoke doors on the 6th Floor.
3. A fire alarm strobe failed to be installed within fifteen feet of the 5th Floor, East Hall smoke doors on the north side of the doors.
4. The 1st Floor Surgery East Hall/PACU Entrance failed to have an audio/visual fire alarm device installed in the area.
In an interview conducted at the time of observations, (11/29/11, from 3:54 pm to 4:20 pm), Engineering A acknowledged the findings.

Based on observation and interview, the facility failed to install the automatic sprinkler system to provide complete and unobstructed coverage for all portions of the building in accordance with NFPA 13. This deficient practice affected all patients, visitors and staff that are in the area of those areas without sprinkler protection. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 10:12 am to 2:54 pm revealed:
1. Closet in Patient Room 502 was used for storage of hospital supplies and failed to provide sprinkler protection.
2. Closet in OT Office was used for storage of supplies and failed to provide sprinkler protection.
3. The small Storage Room next to Purchasing in the Ground floor failed to provide sprinkler protection.
During an interview on 11-29-11 at times of observations Engineering B confirmed the lack of sprinkler protection.



27395

Observations during the facility tour on 11/29/11, from 1:16 pm to 1:49 pm revealed:
1. The 1st Floor Radiology Special Procedures Room failed to have sprinkler protection in the North Storage area behind the sliding glass partition.
2. The facility failed to install sprinkler heads at least 6 inches away from exam lights that obstructed sprinkler heads in ER Exam Rooms 2 and 3.
During an interview on 11-29-11 at the times of observations, Engineering A confirmed the lack of sprinkler protection and the obstructed sprinkler heads.

Actual NFPA Standard:
5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

Based on observation and interview, the facility failed to install the automatic sprinkler system to provide unobstructed coverage for all portions of the building in accordance with NFPA 13. This deficient practice affected all patients, visitors and staff that are in the area of those areas without sprinkler protection. The facility capacity is 173 and the census was 52.

Findings are:
Observation on 11/29/11, at 9:28 am revealed a fire alarm conduit installed less than 6 " away from two sprinkler heads in the 7th Floor North Storage Room.
In an interview conducted at the time of observation, (11/29/11, at 9:28 am), Maintenance D acknowledged the findings.

Actual NFPA Standard:
5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

Based on observation, record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing. All smoke compartments and all occupants could be affected by the deficient practice. At the time of the survey the census was 52.

Findings are:
1. Documentation review on 11/29/11 of the fire sprinkler reports revealed the sprinkler system had an annual inspection on 5/26/11. Noted on the report was " (fire pump) control valves for the jockey pump are not secured in the open position " . Interview with Engineering C on 11/29/11 at 10:35 am revealed the failure of this to be corrected.
2. Documentation review of the fire alarm inspection reports dated 3/23/11, 6/23/11, and 9/15/11 revealed 100% of the flow switches had not been tested. A partial count of the flow switches had been documented at each of the inspections. The last report for 100% flow switch testing was dated 12/7/10 by the fire alarm inspectors.
3. Interview with Engineering C on 11/29/11 at approximately 11:10 am revealed the flow switches tested by the Fire alarm company could not be verified as to which flow switches had been tested. In addition Engineering C stated that he conducted flow switch inspections on 11/10/10, 2/8/11, 5/12/11 and 8/11/11. Review of the fire alarm activation report revealed only the 8/11/11 test had been received at the central receiving.
4. No documentation of a five year obstruction testing could be provided for review.
Interview with Engineering C at this time confirmed the findings.
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1



13879

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that sprinkler heads are installed as required. This deficient practice effected patients, staff and visitors on the 5th floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:54 am revealed the escutcheon in Patient Room 514 restroom was hanging from the ceiling.
During an interview on 11-29-11 at 9:54 am, Engineering B confirmed the findings.



27395

Observations on 11/29/11, from 9:24 am to 11/30/11, at 3:58 pm revealed:
1. In the North Stair Tower outside of the 9th Floor Mechanical Room, a sprinkler head had masking tape wrapped around it.
2. A sprinkler head in the 1st Floor Radiology Reading Room failed to have an escutcheon ring installed.
3. A sprinkler head in the 1st Floor Histology Conference Room failed to have an escutcheon ring installed.
4. A sprinkler head in the 1st Floor Old CP Waiting Room failed to have an escutcheon ring installed.
5. The Ground Level Social Services Office had a hole in the ceiling tile around the sprinkler head towards the back of the Room.
In an interview conducted at the times of observations, (11/29/11, from 9:24 am to 11/30/11, at 3:58 pm), Engineering C acknowledged the findings.

NFPA Standard:
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

Based on observation and staff interview, the facility failed to keep a sprinkler head free of obstructions. This condition had the potential to interrupt the discharge pattern of the sprinkler head. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/28/11, at 2:02 pm revealed a Biodex Fall Protection Device was positioned within six inches of a sprinkler head. The facility failed to maintain the sprinkler head free of obstructions.
In an interview conducted at the time of observation, (11/28/11, at 2:02 pm) Engineering C acknowledged the obstruction to the sprinkler head.

Based on observation and staff interview, the facility failed to keep ceiling tiles in place in the suspended ceiling. This condition had the potential to allow heat to escape from around sprinkler heads and delay their reaction. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/28/11, at 2:28 pm revealed a missing ceiling tile and a broken tile in the Communication Room.
In an interview conducted at the time of observation, (11/28/11, at 2:28 pm), Engineering C acknowledged the findings.

Based on observation and staff interview, the facility failed to protect cooking equipment in accordance with NFPA, 96. This condition had the potential for fire spread quickly due to grease laden vapors emitted during cooking from unprotected cooking equipment. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/29/11, at 2:55 pm revealed:
1. A Panini Grill was used in the 1st Floor Cafe, and failed to be protected by a range hood suppression system. Grease was observed under the cabinet, above the grill and char was observed in the grill, due to a butter spray used with the grill.
2. The range hood in the 1st Floor Cafe failed to have filters that were not constructed of mesh material.
In an interview conducted at the time of observation, (11/29/11, at 2:55 pm), Engineering A acknowledged the findings.

Actual NFPA Standard:
Nebraska State Fire Marshal Official Interpretation 03-02.

NFPA 96, 6.2.3 Grease Filters.
6.2.3.1 Grease filters shall be listed and constructed of steel or listed equivalent material.
6.2.3.2 Grease filters shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions.
6.2.3.3 Grease filters shall be arranged so that all exhaust air shall pass through the grease filters.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected patients, visitors and staff in the Ground Floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 2:15 pm and 3:11 pm revealed an approximate 56 foot long corridor filled with mobile soiled linen carts.

During an interview on 11-29-11 at 3:11 pm, Engineering B confirmed the soiled linen carts which filled the length of the 56 foot corridor and stated that housekeeping places them there for pick-up from a delivery service.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and interview, the facility failed to maintain the facility free from decorations of a highly flammable nature or provide the flame retardancy rating for decorations on corridor walls in the 5th floor Day Room. This deficient practice has the potential for smoke to migrate in the exiting corridors. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:45 am revealed a 36 inch by 25 inch fabric wall hanging in the 5th floor Day Room.

During an interview on 11-29-11 at 9:54 am, Engineering B confirmed the fabric wall hanging and stated that it had not been treated with any type of flame resistance.

NFPA Standard:
Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Except that some combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. 2000 NFPA 101, 18/19.7.5.4
Decorations and furnishings that do not meet the definition of interior finish shall be regulated by the provisions of Section 10.3. 2000 NFPA 101, 10.2.4.6
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1

Based on observation and interview, the facility failed to maintain the facility free from highly flammable curtains or provide the flame retardant rating for the curtains in Patient Rooms 500, 501, 502, 504 and Day Room. This deficient practice has the potential for smoke and fire to migrate in the exiting corridors on the 5th floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 9:45 am and 10:15 am revealed:
1. Curtains on two of three windows in the 5th floor Day room failed to provide label for fire resistance.
2. Curtain on 5th floor Day room cabinets failed to provide label for fire resistance.
3. Curtain on the inside of Patient 500 door window failed to provide fire resistance label.
4. Curtain on the inside of Patient 501 door window failed to provide fire resistance label.
5. Curtain on the inside of Patient 502 door window failed to provide fire resistance label.
6. Curtain on the inside of Patient 504 door window failed to provide fire resistance label.

During an interview on 11-29-11at each time of observation, Engineering B confirmed the fabric curtains, and failed to provide documentation for the flame resistance.

NFPA Standard:
Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.1

Based on observation and interview, the facility failed to have signage for medical gas cylinders in storage, which is in accordance with NFPA 99. This deficient practice affected all residents, staff and visitors on 5th, 4th and 2nd floors of the facility. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 10:19 am to 1:42 pm revealed:
5th Floor:
1. No oxygen signage outside Storage Room in the east corridor across from room 505.
4th Floor:
2. No oxygen signage outside Storage Room 4004, across from room 432.
2nd Floor:
3. No oxygen signage outside Storage Room 2215.
4. No oxygen signage outside Storage Room 2009.
During an interview on 11-29-11 at times of observations, Engineering B confirmed the lack of oxygen signage for storage of oxygen cylinders.

NFPA Standard:
Precautionary signs, readable from a distance of 5 feet, shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. 1999 NFPA 99, 8-6.4.2

Based on observation and interview the facility failed to maintain the Level 1 Emergency Power Supply System in accordance with NFPA 110, Standard for Emergency and Standby Power Systems 1999 Edition by not providing the required fire rated separation of the Emergency Power Supply (EPS) and the Main normal electrical switchgear. Because the generators supply emergency power to the entire hospital facility this deficient practice has the potential to affect all residents, staff and visitors of the facility. The facility capacity is 173 and the census was 52.

Findings Are:
Observation on November 29, 2011 at 9:20am revealed that the doors between the generator room and the main electrical switchgear room were not installed in a fire-rated frame and did not have a fire-rating label installed on the doors themselves. The doors were also not self-closing and positive latching. This observation was confirmed in an interview with Engineering E at the above date and time.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branches of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 173 and the census was 52.

Findings Are:
1. Observation on November 29, 2011 at 8:50am revealed that there was the following life safety loads connected to the critical branch panel GCL1: #1 Generator enclosure panel with lights and receptacles. This observation was confirmed in an interview with Engineering E at the above date and time.
2. Observation on November 29, 2011 at 9:12am revealed that there was the following life safety loads connected to the equipment system panel GEL2: #1 Generator Battery Charger; #5 Emergency Lighting; #6 Ground Floor Emergency Lighting; #7 First floor emergency lighting; #18 Generator Battery Charger. This observation was confirmed in an interview with Engineering E at the above date and time.
3. Observation on November 29, 2011 at 9:32am revealed that there was the following critical branch loads connected to the equipment system panel GLENB: #8,10,12 Pharmacy Sub Panel; 19, 20, & 21 Lab outlets. This observation was confirmed in an interview with Engineering E at the above date and time.
4. Observation on November 29, 2011 at 9:42am revealed that there were the following critical loads connected to the equipment system panel EMGA: #8 Nurse Call and #10 Nurse Call. This observation was confirmed in an interview with Engineering E at the above date and time.
6. Observation on November 29, 2011 at 10:03am revealed that there was the following life safety load connected to the equipment system panel GHENA: #2 Exit Lights. This observation was confirmed in an interview with Engineering E at the above date and time.
7. Observation on November 29, 2011 at 10:09am revealed that there was the following life safety loads connected to the equipment system panel GLENA-SUB: #14 Canopy Lights, #16 Canopy Lights, and #18 Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
8. Observation on November 29, 2011 at 10:09am revealed that there was the following critical branch loads connected to the equipment system panel GLENA-SUB: #2 Lab, #4 Lab, #6 Lab, #8 Lab, #9 Nuclear Med, and #10 Nuclear Med. This observation was confirmed in an interview with Engineering E at the above date and time.
9. Observation on November 29, 2011 at 10:19am revealed that there was the following life safety loads connected to the equipment system panel DEC-1: #8 Night Lights and Exit Lights and #18 Server Room Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
10. Observation on November 29, 2011 at 10:28am revealed that there was the following Critical Loads connected to the normal power panel1L2: Nurse Call. This observation was confirmed in an interview with Engineering E at the above date and time.
11. Observation on November 29, 2011 at 10:31am revealed that there were the following non-critical loads connected to the critical branch panel EC1B: #19 TV outlet sleep room and #27 Sump pump. This observation was confirmed in an interview with Engineering E at the above date and time.
12. Observation on November 29, 2011 at 10:35am revealed that there was the following life safety loads connected to the equipment system panel 1HEL1: #1 1st floor exit lights, #2 1st floor emergency lights, #10 ground floor exit lights, #11 ground floor emergency lights, #13 emergency lights in OR 1 and OR 2, and #14 emergency lights sub-basement. This observation was confirmed in an interview with Engineering E at the above date and time.
13. Observation on November 29, 2011 at 10:46am revealed that there was the following critical branch loads connected to the life safety panel E1C: #26 Pyxis Rec Cardio Equipment, and #28 Nurse Call by Elevators. This observation was confirmed in an interview with Engineering E at the above date and time.
14. Observation on November 29, 2011 at 10:46am revealed that there was the following equipment system loads connected to the life safety panel E1C: #17 Chiller Heat Tape, #21 Rec, #22 Rec Doctors Dictation, #23 Rec, and #24 Johnson Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
15. Observation on November 29, 2011 at 10:49am revealed that there was the following non-life safety loads connected to the life safety panel E1B: #23 Cart Lift, #24 East Cart Lift, #26 West Cart Lift, and #28 Cat Lift Sump Pump. This observation was confirmed in an interview with Engineering E at the above date and time.
16. Observation on November 29, 2011 at 10:53am revealed that there were the following non-critical loads connected to the critical branch panel EC1D: #2 Auto Doors, #4 Auto Doors, #26 Auto Doors, #80 Johnson Controls, #82 Johnson Controls, and #84 Johnson Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
17. Observation on November 29, 2011 at 10:56am revealed that there were the following non-critical loads connected to the critical branch panel EC1F: #15 Auto Doors, #38 AHU#23 Equipment Power, #39 Penthouse heat tape, #40 Trane Control, and #41 Penthouse Lights. This observation was confirmed in an interview with Engineering E at the above date and time.
18. Observation on November 29, 2011 at 11:26am revealed that there was the following life safety loads connected to the equipment system panel 1LENA: #39 New Fire Alarm Panel. This observation was confirmed in an interview with Engineering E at the above date and time.
20. Observation on November 29, 2011 at 1:04pm revealed that there was the following non-life safety loads connected to the Bio-Med life safety panel: #1 North Rec Mikes Office, #5 North Outside Receptacle, and #7 North Outside Receptacle. This observation was confirmed in an interview with Engineering E at the above date and time.
21. Observation on November 29, 2011 at 1:10pm revealed that there was the following life safety loads connected to the equipment system panel EMGB: #19 New Fire Alarm Panel. This observation was confirmed in an interview with Engineering E at the above date and time.
22. Observation on November 29, 2011 at 1:12pm revealed that there was the following non-life safety loads connected to the life safety panel EGB: #1 Elevator pit alarm, #3 elevator pit, #5 time clock, #7 SW Sign, #9 Receptacle Kronos Home health, #12 Johnson Controls, #16 Elevator sump pump, and #18 Elevator pit light and receptacle. This observation was confirmed in an interview with Engineering E at the above date and time.
23. Observation on November 29, 2011 at 1:31pm revealed that there was the following non-life safety loads connected to the life safety panel 2LL1: #7 2nd Floor HUGS Power. This observation was confirmed in an interview with Engineering E at the above date and time.
24. Observation on November 29, 2011 at 1:33pm revealed that there were the following non-critical loads connected to the critical branch panel 2CL1: Johnson Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
25. Observation on November 29, 2011 at 1:49pm revealed that there were the following life safety loads connected to the equipment system panel GEL1: #32,34 Telephone room panel, #36 Hospital Paging Cabinet, #41 Fire Alarm and #42 Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
26. Observation on November 29, 2011 at 1:52pm revealed that there was the following life safety loads connected to the phone room equipment system panel: #5 Plug Mold North, #6 Outlet above east phone board, #7 Plugmold West, #9 South wall raised receptacle left, and #11 south wall raised receptacle right. This observation was confirmed in an interview with Engineering E at the above date and time.
27. Observation on November 29, 2011 at 2:07pm revealed that there was the following life safety loads connected to the critical branch panel 3EL1: #18 Tel Com Rm Fire alarm panel. This observation was confirmed in an interview with Engineering E at the above date and time.
28. Observation on November 29, 2011 at 2:11pm revealed that there was the following life safety loads connected to the critical branch panel 3HEL1: #1 Emergency lights, #3 Exit Lights, #6 Emergency Lights, and #9 Emergency and exit lights south stair tower. This observation was confirmed in an interview with Engineering E at the above date and time.
29. Observation on November 29, 2011 at 2:14pm revealed that there were the following non-critical loads connected to the critical branch panel 3EL2: #42 Security Door. This observation was confirmed in an interview with Engineering E at the above date and time.
30. Observation on November 29, 2011 at: 2:20pm revealed that there were the following non-critical loads connected to the critical branch panel 4CL1: #18 Trane Power. This observation was confirmed in an interview with Engineering E at the above date and time.
31. Observation on November 29, 2011 at 2:39pm revealed that there was the following life safety loads connected to the critical branch panel ELP7: #14 Fire Alarm, and #26 Emergency lights 7th Floor. This observation was confirmed in an interview with Engineering E at the above date and time.
32. Observation on November 29, 2011 at 2:39pm revealed that there were the following non-critical loads connected to the critical branch panel ELP7: #13 Door Locks, and #16 Trane Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
33. Observation on November 29, 2011 at 2:55pm revealed that there was the following life safety loads connected to the equipment system panel 9th floor EM panel: #2 Elevator 1 Cab lights. #4 Elevator 2 Cab Lights, #11 Elevator 4 Cab Lights, and #13 Elevator 3 Cab Lights. This observation was confirmed in an interview with Engineering E at the above date and time.
34. Observation on November 29, 2011 at 3:10pm revealed that there was the following life safety load connected to the equipment system panel 9EL1: #5 Elevator Shaft Damper Motor. This observation was confirmed in an interview with Engineering E at the above date and time.
35. Observation on November 29, 2011 at 4:39pm revealed that there was the following life safety load connected to the normal panel GL5: #10 Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
36. Observation on November 29, 2011 at 4:42pm revealed that there was the following equipment system loads connected to the normal power panel GHP2: Kitchen Exhaust hoods. This observation was confirmed in an interview with Engineering E at the above date and time.
37. Observation on November 29, 2011 at 4:48pm revealed that there was the following life safety load connected to the normal panel GL6: #43 Fire Alarm this room. This observation was confirmed in an interview with Engineering E at the above date and time.
38. Observation on November 29, 2011 at 4:48pm revealed that there was the following equipment system load connected to the normal panel GL6: #37 and #46 Hood Exhaust fan and controls. This observation was confirmed in an interview with Engineering E at the above date and time.
39. Observation on November 29, 2011 at 4:56pm revealed that there was the following life safety loads connected to the generator critical branch panel: #1 Generator room lights, #3 Generator Room Receptacles, #7 Generator Battery Charger, #13 Inside Receptacle and #16 Emergency light. This observation was confirmed in an interview with Engineering E at the above date and time.
40. Observation on November 29, 2011 at 4:56pm revealed that there was the following non-critical loads connected to the generator critical branch panel: #2,4 Jacket Heater, #5 Damper Motor, #6,10 Room Heater, #9,11 Tank Heater, #10,12 Space Heater, and #14 Outside Receptacle. This observation was confirmed in an interview with Engineering E at the above date and time.

NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7?C (20?F).
(b) The outside design temperature is lower than -6.7?C (20?F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This practice affected all patients, visitors and staff on the 5th floor and Ground Floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 9:40 am to 2:50 pm revealed:
5th Floor:
1. Power strip used as permanent wiring for a Television, DVD, VCR and WII in the 5th floor Day Hall.
2. Power strip used as permanent wiring for the fish tank and equipment in the 5th floor Day Hall.
Ground Floor:
3. Storage of items in front of the panel box in Bio-Med room.
4. Refrigerator plugged into a power strip under the desk of the Store Room Clerk office area in Purchasing Room.
During an interview on 11-29-11 at each time of observation, Engineering B confirmed the findings.



20404

Based on observation and interview the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, National Electrical Code 1999ed. by not having complete and accurate circuit directories, by not maintaining panels such that they are dead front with no exposed live buss, by not having signage to indicate the locations of emergency power systems, and by not having the required working clearances in front of electrical equipment that requires servicing. These deficient practices are located throughout the facility and put the entire electrical system at risk, pose a greater fire hazard to the facility and leave persons exposed to possible electric shock hazards. The facility capacity is 173 and the census was 52.

Findings Are:
1. Observation on November 29, 2011 at 9:25am revealed that the motor control center in the west equipment room was not labeled or identified. This observation was confirmed in an interview with Engineering E at the above date and time.
2. Observation on November 29, 2011 at 10:09am revealed that there was no signage installed at any of the service entrance locations to indicate the types and locations of on-site emergency power sources. This observation was confirmed in an interview with Engineering E at the above date and time.
3. Observation on November 29, 2011 at 9:42am revealed that there was no panel schedule installed in or on the equipment system panel EMGA. This observation was confirmed in an interview with Engineering E at the above date and time.
4. Observation on November 29, 2011 at 10:09am revealed that the equipment system motor control center N2 was not labeled or identified. This observation was confirmed in an interview with Engineering E at the above date and time.
5. Observation on November 29, 2011 at 10:38am revealed that the circuit directory for the equipment system panel EM1A was not complete and was not identified at the panel ahead of it EMGA. This observation was confirmed in an interview with Engineering E at the above date and time.
6. Observation on November 29, 2011 at 11:09am revealed that the circuit directory for the equipment system panel EM1B was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
7. Observation on November 29, 2011 at 11:39am revealed that the equipment system panel GEL3 circuit directory was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
8. Observation on November 29, 2011 at 1:04pm revealed that the life safety panel bio-med was not dead front and had exposed live buss. This observation was confirmed in an interview with Engineering E at the above date and time.
9. Observation on November 29, 2011 at 1:04pm revealed that the life safety panel bio-med circuit directory was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
10. Observation on November 29, 2011 at 1:04pm revealed that the life safety panel bio-med did not have the required working clearances in front of the panel to allow ready access to the panel in an emergency. This observation was confirmed in an interview with Engineering E at the above date and time.
11. Observation on November 29, 2011 at 1:10pm revealed that there was not the required working clearances in front of the equipment system panel EMGB and the normal panel LGC. This observation was confirmed in an interview with Engineering E at the above date and time.
12. Observation on November 29, 2011 at 2:09pm revealed that the circuit directory for the critical branch panel 3EL1/S was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
13. Observation on November 29, 2011 at 2:11pm revealed that the circuit directory for the critical branch panel 3HEL1 was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
14. Observation on November 29, 2011 at 2:40pm revealed that the circuit directory for the critical branch panel ELP7 was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
15. Observation on November 29, 2011 at 2:54pm revealed that the circuit directory for the equipment system panel 9HEP was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
16. Observation on November 29, 2011 at 4:31pm revealed that the life safety panel on the 7th floor was not identified and there was no circuit directory installed in or on the panel. This observation was confirmed in an interview with Engineering E at the above date and time.
17. Observation on November 29, 2011 at 4:31pm revealed that the life safety panel on the 7th floor was not dead front and had exposed live buss. This observation was confirmed in an interview with Engineering E at the above date and time.
18. Observation on November 29, 2011 at 4:48pm revealed that the circuit directory for the normal panel GL6 was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.

NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

NFPA 70, 1999ed.
110.26 Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
Table 110.26(A)(1) Working Spaces

Nominal Voltage to Ground Minimum Clear Distance
Condition 1 Condition 2 Condition 3
0-150 900 mm (3 ft) 900 mm (3 ft) 900 mm (3 ft)
151-600 900 mm (3 ft) 1 m (3? ft) 1.2 m (4 ft)

Note: Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switchboards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on nonelectrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all uninsulated parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volts dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 750 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(E). Within the height requirements of this section, other equipment that is associated with the electrical installation and is located above or below the electrical equipment shall be permitted to extend not more than 150 mm (6 in.) beyond the front of the electrical equipment.
(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(C) Entrance to Working Space.
(1) Minimum Required. At least one entrance of sufficient area shall be provided to give access to working space about electrical equipment.
(2) Large Equipment. For equipment rated 1200 amperes or more and over 1.8 m (6 ft) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance to the required working space not less than 610 mm (24 in.) wide and 2.0 m (6? ft) high at each end of the working space. Where the entrance has a personnel door(s), the door(s) shall open in the direction of egress and be equipped with panic bars, pressure plates, or other devices that are normally latched but open under simple pressure.
A single entrance to the required working space shall be permitted where either of the conditions in 110.26(C)(2)(a) or (b) is met.
(a) Unobstructed Exit. Where the location permits a continuous and unobstructed way of exit travel, a single entrance to the working space shall be permitted.
(b) Extra Working Space. Where the depth of the working space is twice that required by 110.26(A)(1), a single entrance shall be permitted. It shall be located so that the distance from the equipment to the nearest edge of the entrance is not less than the minimum clear distance specified in Table 110.26(A)(1) for equipment operating at that voltage and in that condition.
(D) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting outlets shall not be required where the work space is illuminated by an adjacent light source or as permitted by 210.70(A)(1), Exception No. 1, for switched receptacles. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.
(E) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 2.0 m (6? ft). Where the electrical equipment exceeds 2.0 m (6? ft) in height, the minimum headroom shall not be less than the height of the equipment.
Exception: In existing dwelling units, service equipment or panelboards that do not exceed 200 amperes shall be permitted in spaces where the headroom is less than 2.0 m (6? ft).
(F) Dedicated Equipment Space. All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage.
Exception: Control equipment that by its very nature or because of other rules of the Code must be adjacent to or within sight of its operating machinery shall be permitted in those locations.
(1) Indoor. Indoor installations shall comply with 110.26(F)(1)(a) through (d).
(a) Dedicated Electrical Space. The space equal to the width and depth of the equipment and extending from the floor to a height of 1.8 m (6 ft) above the equipment or to the structural ceiling, whichever is lower, shall be dedicated to the electrical installation. No piping, ducts, leak protection apparatus, or other equipment foreign to the electrical installation shall be located in this zone.
Exception: Suspended ceilings with removable panels shall be permitted within the 1.8-m (6-ft) zone.
(b) Foreign Systems. The area above the dedicated space required by 110.26(F)(1)(a) shall be permitted to contain foreign systems, provided protection is installed to avoid damage to the electrical equipment from condensation, leaks, or breaks in such foreign systems.
(c) Sprinkler Protection. Sprinkler protection shall be permitted for the dedicated space where the piping complies with this section.
(d) Suspended Ceilings. A dropped, suspended, or similar ceiling that does not add strength to the building structure shall not be considered a structural ceiling.
(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in 110.26(A). No architectural appurtenance or other equipment shall be located in this zone.

NFPA 70, 1999ed. 384-18. Enclosure.
Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.

NFPA 70, 1999ed. 700-8. Signs.
(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.



27395

Observations during the facility tour on 11/28/11, from 3:33 pm to 11/30/11, at 10:41 am revealed:
1. The facility failed to close the open junction box above ceiling on 6th Floor at the can light outside of Room 618.
2. The facility failed to close the open junction box above ceiling on 6th Floor above the North Stair Tower Door.
3. The facility failed to close the open junction box in the 3rd Floor Biomed Northwest Storage Room.
4. On the 1st Floor in the Mamography Room, the electrical receptacles built into the Mamo Desk were exposed and laying on the floor.
5. The facility failed to close two open junction boxes in the 1st Floor MRI Equipment Room.
6. The facility failed to close the open junction box above the double doors north of Elevator 4 on the 1st Floor.
7. On the 1st Floor above the time clock on the west side of the Lab, open blanks were observed in a junction box above ceiling.
In an interview conducted at the times of observations, (11/28/11, from 3:33 pm to 11/30/11, at 10:41 am), Engineering C acknowledged the findings.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8, 1999 NFPA 110, 6.4.1 and 6.4.2

Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. 2002 NFPA 70, 110.26

Based on observation and staff interview, the facility failed to use electrical equipment in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical shock. Facility census was 52 of 173.

Findings are:

Observation during the facility tour on 11/28/11 at 1:58 pm revealed a missing cover plate from a wall outlet in the PFT Room.
In an interview conducted at the time of observation, (11/28/11 at 1:58 pm), Engineering C acknowledged the findings.

Based on observation and staff interview, the facility failed to separate use areas from corridors by smoke resisting partitions. This condition had the potential to allow smoke to migrate into the exit corridor. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/29/11, at 11:14 am revealed a hole around a pipe above ceiling at Room 622 on the 6th Floor.
In an interview conducted at the time of observation, (11/29/11, at 11:14 am), Engineering C acknowledged the corridor wall penetration.

Based on observation and staff interview, the facility failed to separate use areas from corridors by smoke resisting partitions. This condition had the potential to allow smoke to migrate into the exit corridor. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/30/11, from 10:59 am to 1:58 pm revealed:
1. The temporary 1st Floor Cardio Staff Office wall failed to extend to the deck above the suspended ceiling.
2. Above ceiling at the 1st Floor Double Doors near Room 1035 Director of Diagnostic Imaging revealed a penetration in the corridor wall.
3. On the Ground Level above ceiling at the Director of Pharmacy Office revealed a penetration around a 6 inch sprinkler main in the corridor wall.
In an interview conducted at the time of observation, (11/30/11, from 10:59 am to 1:58 pm), Engineering C acknowledged the corridor wall penetrations.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 2:01 pm on the 2nd Floor revealed a wood door chock holding open the Nursery Door 2210.
During an interview on 11-29-11 at 2:01 pm, Engineering B confirmed the chock holding open the door and removed it immediately.

Based on observation and interview the facility failed to maintain the doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas such that they are substantial doors, such as those constructed of 1 3/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes and are provided with a positive latching means for keeping the door closed. They shall also resist the passage of smoke. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:57 am revealed a metal coat rack holding open the door to the 5th floor visitor waiting room.
During an interview on 11-29-11 at 9:57 am, Engineering B confirmed the coat rack in front of the door and removed it immediately.



27395

Observations during the facility tour on 11/29/11, from 9:35 am to 11/30/11 at 3:25 pm revealed:
1. The 7th Floor Conference Room 700 Door had four pencil size holes that penetrated the door.
2. The Ground Level Vending Machine Room Door failed to latch when swung shut by the automatic closure.
3. The Ground Level Telephone Closet by the South Addition failed to have positive latching hardware installed in the door.
4. The 1st Floor PACU Bay 13 sliding door failed to latch when pulled shut.
In an interview conducted at the times of observation, (11/29/11, from 9:35 am to 11/30/11 at 3:25 pm), Engineering C acknowledged the findings.

Based on observation and interview, the facility failed to maintain the vertical opening which provides a minimum 1-hour fire rating. This deficient practice affected all patients, staff and visitors using the North Stair Tower. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:28 am revealed the door on the 5th floor North stair tower failed to close and latch, due to air pressure within the stair enclosure.
During an interview on 11-29-11 at 9:29 am, Engineering B confirmed the North stair tower door on the 5th floor failed to latch within the door frame.

Based on observation and interview, the facility failed to maintain the vertical opening which provides a minimum 1-hour fire rating. This deficient practice had the potential to allow fire to penetrate floor openings more quickly. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-28-11, from 3:26 pm to 11-30-11 at 9:46 am revealed:
1. Inside the 7th Floor East Corridor North Wire Closet, conduits were removed, which left a penetration through the floor assembly.
2. Inside the 3rd Floor East Corridor 2nd Wire Closet, two conduits were removed, which left a penetration through the floor assembly to the 2nd Floor.
3. Inside the 3rd Floor East Corridor North Wire Closet, conduits were removed, which left a penetration through the floor assembly.
4. The 1st Floor Northeast Exit Stairwell to the MSB Link failed to maintain 1-hour fire separation throughout the stairwell. A sliding glass door on the first floor that separated the Hospital from the Stairwell failed to meet the required 1-hour fire separation.
During an interview on (11-28-11, from 3:26 pm to 11-30-11 at 9:46 am), Engineering C confirmed the penetrations in the vertical separations.

Actual NFPA Standard:
NFPA 101, 19.3.1 Protection of Vertical Openings.
19.3.1.1
Any vertical opening shall be enclosed or protected in accordance with 8.2.5. Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating.

Based on observation and interview, the facility failed to ensure that 2 of 2 sets smoke separation doors are capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread throughout the 4th floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 11:37 am and 1:05 pm revealed:
1. The space between the smoke doors next to Room 427 was greater than 1/8 inch.
2. The space between the smoke doors next to Conference Room 4411 was greater than 1/8 inch.
During an interview on 11-29-11 at 11:37 am and 1:05 pm, Engineering B confirmed the space between the doors were greater than 1/8 inch.

NFPA Standard:
Requires doors in smoke barriers to be self-closing and resist the passage of smoke, NFPA 101, 18.3.7.6*.

Based on observation and interview, the facility failed to ensure that a smoke separation door is capable of resisting the passage of smoke as the doors would allow smoke and gasses to spread throughout the Ground Level. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11/30/11, at 3:19 pm revealed the Ground Level Double Doors by OR 5 failed to latch when swung shut.
During an interview on (11/30/11 at 3:19 pm), Engineering C confirmed the doors failed to latch.

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential to spread into the egress corridors. Facility census was 52 of 173.

Findings are:
Observations on 11-29-11 from 9:45 am to 2:54 pm revealed:
5th Floor:
1. Telephone closet door on the 5th floor failed to provide latching device, only a dead bolt lock.
2. Staff only/Break room on the 5th floor across from room 502 failed to latch within the door frame.
3. Electrical closet door on the east side of building across from room 505 failed to provide latching device, only a dead bolt lock.
4. Electrical chase door on the 5th floor failed to provide latching device, only a dead bolt lock.
5. Wire closet door across from Therapy/Gym on the 5th floor failed to provide latching device, only a dead bolt lock.
Ground Floor:
6. Purchasing door next to the small storage room in the Ground floor failed to close and latch within door frame.
During an interview on 11-29-11 at times of observations, Engineering B confirmed all the findings.



27395

Findings are:
Observations during the facility tour on 11/29/11, from 10:52 am to 11/30/11, at 3:12 pm revealed:
1. Holes around cables and conduits on the 7th Floor above ceiling in the North Soiled Utility Room.
2. All 3rd Floor Electrical and Phone Closet Doors failed to have positive latching hardware installed in the doors.
3. The automatic closure failed to be installed on the 1st Floor Histology Lab South Door. The automatic closure had been removed on the day of the survey.
4. The 1st Floor Radiology Room west of the Flouro Room measured over 50 square feet with combustible storage inside. The facility failed to install an automatic closure on the room door.
5. The 1st Floor Hot Lab, which was used for the storage of radioactive material, failed to have an automatic closure installed on the door. A louver installed in the Hot Lab Wall opened the room to the Nuclear Medication Room 2, which is a patient care area. The facility failed to seal the louver with smoke resisting partitions.
6. The Ground Level Kitchen Storage Room failed to have positive latching hardware installed in the door.
7. The Ground Level Morgue Elevator Equipment Room failed to latch when swung shut. A metal plate was attached over the latch, which allowed the door to close without latching.
In an interview conducted at the time of observation, (11/29 am, from 10:52 am to 11/30/11, at 3:12 pm), Engineering C acknowledged the findings.

NFPA Standard:
Hazardous areas shall be safeguarded by a fire barrier of one-hour fire resistance rating or provided with an automatic sprinkler system and doors shall have self-closing devices and positive latches. 2000 NFPA 101, 19.3.2.1 and 2000 NFPA 101, 8.4.1

Based on observation and staff interview, the facility failed to provide separation of hazardous areas from other compartments. This condition had the potential to spread into the egress corridors. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/29/11, from 9:27 am to 1:05 pm revealed:
1. The 7th Floor North Storage Room Double Doors failed to latch when swung shut.
2. Above Ceiling on the 6th Floor above Soiled Utility 6016 revealed a penetration in the corridor wall.
3. The Double Doors failed to latch when swung shut to the 1st Floor Shell Space east of the North Elevator used as storage.
In an interview conducted at the time of observation, (11/29/11, from 9:27 am to 1:05 pm), Engineering D acknowledged that the doors failed to latch.

Based on observation and staff interview, the facility failed to provide a smoke resisting partition to separate the Gift Shop from the corridor. This condition had the potential to allow smoke and fire to migrate from the Gift Shop to the exit corridor. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/28/11, at 12:54 pm revealed the Gift Shop Sliding Glass Doors failed to have positive latching hardware installed in the doors. The Gift Shop exceeded 500 square feet to meet the exception to allow it to be open to the corridor.
In an interview conducted at the time of observation, (11/28/11, at 12:54 pm), Engineering C acknowledged the square footage of the Gift Shop, and that no positive latching hardware was installed in the doors.

Based on observation and staff interview, the facility failed to maintain stairwell enclosure doors so that they latched when closed. This condition had the potential to allow smoke or fire to migrate into the exit enclosures. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/28/11, from 2:04 pm to 2:16 pm revealed:
1. The East Staircase, 2nd Floor Door failed to latch when closed.
2. The West Staircase, 2nd Floor Door failed to latch when closed.
In an interview conducted at the times of observation, (11/28/11, from 2:04 pm to 2:16 pm), Engineering C acknowledged that the doors failed to latch.

Based on observation and staff interview, the facility failed to provide a new stair tower that only allowed access into the stair tower from normally occupied areas. This condition had the potential to allow smoke and fire directly into the stair tower from a mechanical room. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/29/11, at 9:25 am, revealed the New North Stair Tower 9th Floor Elevator Equipment Room opened directly into the stair tower. The facility failed to prohibit the room from entering directly into the stair tower.
In an interview conducted at the time of observation, (11/29/11, at 9:25 am), Maintenance C confirmed that the mechanical room opened directly into the stair tower.

Actual NFPA Standard:
NFPA 101, 7.1.3.2.1 (d) Openings in exit enclosures shall be limited to those necessary for access to the enclosure from normally occupied spaces and corridors and for egress from the enclosure.

Based on observation and staff interview, the facility failed to provide a locked egress device that would release with the activation of the fire alarm. This deficient practice affects all patients, staff and visitors on the seventh floor of the building that may need to evacuate the building. The facility census was 52.
Findings are:
During the fire alarm testing on 11/29/11 from approximately 3:55 pm through 4:30 pm revealed the failure of the magnetic locks on the two north exits from releasing during the fire alarm testing. Interview with Engineering C at this time confirmed the failure of the two exit doors from releasing during the fire alarm testing.

NFPA Standard: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1
NFPA Standard: Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, except delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path. 2000 NFPA 101, 19.2.2.2.4

Based on observation and staff interview, the facility failed to maintain a horizontal exit door in accordance with the National Fire Protection, 101. This condition had the potential to allow the doors to swing open during a fire due to the superheated gases from the fire conditions, spreading smoke and fire throughout the exit corridors. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/30/11, 2:01 pm revealed the 3-hour fire rated doors in the ER Department failed to latch when swung shut.
In an interview conducted at the time of observation, (11/30/11, 2:01 pm), Engineering A acknowledged that the doors failed to latch.

Based on observation and interview, the facility failed to provide an exit sign to indicate the continuous path of egress on the second floor. This deficient practice affected all staff and visitors in an emergency situation on the first floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 4:20 pm revealed the exit sign outside the Ground Level construction area for the new oxygen storage room was obstructed by white plastic film used by the contractors.
During an interview on 11-29-11 at 4:20 pm, Engineering B confirmed the white plastic obstructed the exit sign and stated the sign was not visible.

Based on documentation review and interviews the facility failed to conduct fire drills to include all staff and occupants. In addition the facility failed to include the activation of the fire alarm during the hours of 6:00 am through 9:00 pm or a coded announcement during the hours of 9:00 pm through 6:00 am. This deficient practice effects all occupants including staff, visitors and residents, as the lack of drills can affect the abilities of the staff to respond in the event of an actual emergency. The facility census was 52.

Findings are:
1. Interview with Engineering C on 11/29/11 at between 1:00 pm and 4:00 pm revealed the fire drills conducted at the hospital did not include the entire building as they would walk up to an area and give them a fire scenario. Only the staff in the immediate area would participate. When asked about who was participating in the drills a complete list of all employees working on that day was offered but who had actually participated could not be identified.
2. Documentation review of the fire alarm activation report and the fire drills reports, on 11/29/11, 12/1/11, and 12/5/11 revealed the fire alarm was not activated for all the fire drills conducted during the Day shift and Evening shift fire drills. Documentation for the fire drills conducted indicated the fire alarm had been sounded but could not be verified on the fire alarm activation report. In addition many of the drill forms had the " Did PBX operator report Code Red over intercom/radio? " as NA or not marked at all.
3. Many fire drill reports were incomplete and did not contain the year of the drill just the month and day. In addition all questions were not completed on all the forms.
4. Fire drills conducted in the Surgery were paper drills and not fire evacuation drills including physicians and surgeons.
5. Laboratory quarterly fire drill documentation could not be provided.
Interview with Engineering C at this time confirmed the findings.
NFPA Standard: Requires drills be conducted at least quarterly on each shift under varied conditions to simulate the unusual conditions occurring in case of fire. The fire alarm shall be transmitted during drills although a coded announcement may be used between 9:00 p.m. and 6:00 a.m. The fire alarm shall be transmitted the day before or the day after the coded drill. 2000 NFPA 101, 19.7.1.2
NFPA Standard:
(a) Hazard Assessment.
1. An evaluation shall be made of hazards that could be encountered during surgical procedures. The evaluation shall include hazards associated with the properties of electricity, hazards associated with the operation of surgical equipment, and hazards associated with the nature of the environment.
2. Periodic reviews of surgical operations and procedures shall be conducted with special attention given to any change in materials, operations, or personnel.
(b) Fire Prevention Procedures. Fire prevention procedures shall be established.
(c) Emergency Procedures.
1. Procedures for operating room/surgical suite emergencies shall be developed. Such procedures shall include alarm actuation, evacuation, and equipment shutdown procedures, and provisions for control of emergencies that could occur in the operating room including specific detailed plans for control operations by an emergency control group within the organization or a public fire department.
2. Emergency procedures shall be established for controlling chemical spills.
3. Emergency procedures shall be established for extinguishing drapery, clothing, or equipment fires.
(d) Orientation and Training.
1. New operating room/surgical suite personnel, including physicians and surgeons, shall be taught general safety practices for the area and specific safety practices for the equipment and procedures they will use. 1999 NFPA 99 12-4.1.2.10
2. Continuing safety education and supervision shall be provided, incidents shall be reviewed monthly, and procedures shall be reviewed annually.
3. Fire exit drills shall be conducted periodically.
NFPA Standard: Fire exit drills shall be conducted at least quarterly. Drills shall be so arranged that each person shall be included at least annually. 1999 NFPA 99 10-2.1.4.3

Based on observation and interview, the facility failed to assure that the fire alarm system is installed, maintained and assure that the fire alarm system is installed and maintained in accordance with NFPA 72. This requires audible and visual devices in all common use areas. This deficient practice affected all staff, and visitors in the Laboratory area. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 4:17 pm and 4:19 pm during a fire alarm test revealed:
1. The facility failed to provide an audible and visual device in the laboratory break room.
2. The facility failed to provide an audible and visual device in the laboratory mail/coat/dressing room.
3. White plastic film covering a visual and audible fire alarm device in front of the construction of the new oxygen storage room on the first floor.
During an interview at 11-29-11 at each time of observations, Engineering B confirmed the lack of fire alarm devices in the common use areas.

Based on observation and staff interview, the facility failed to install the fire alarm in accordance with the National Fire Protection Association, 72. These conditions had the potential to not alert occupants of a fire and prevent affective evacuation. Facility census was 52 of 173.

Findings are:
Observations during the facility tour on 11/29/11, from 3:54 pm to 4:20 pm revealed:
1. The facility-wide voice evacuation message failed to notify occupants to evacuate the facility. The message did not give any instruction other than to stay by the speakers and stand by.
2. A fire alarm strobe failed to be installed on the south side of both sets of smoke doors on the 6th Floor.
3. A fire alarm strobe failed to be installed within fifteen feet of the 5th Floor, East Hall smoke doors on the north side of the doors.
4. The 1st Floor Surgery East Hall/PACU Entrance failed to have an audio/visual fire alarm device installed in the area.
In an interview conducted at the time of observations, (11/29/11, from 3:54 pm to 4:20 pm), Engineering A acknowledged the findings.

Based on observation and interview, the facility failed to install the automatic sprinkler system to provide complete and unobstructed coverage for all portions of the building in accordance with NFPA 13. This deficient practice affected all patients, visitors and staff that are in the area of those areas without sprinkler protection. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 10:12 am to 2:54 pm revealed:
1. Closet in Patient Room 502 was used for storage of hospital supplies and failed to provide sprinkler protection.
2. Closet in OT Office was used for storage of supplies and failed to provide sprinkler protection.
3. The small Storage Room next to Purchasing in the Ground floor failed to provide sprinkler protection.
During an interview on 11-29-11 at times of observations Engineering B confirmed the lack of sprinkler protection.



27395

Observations during the facility tour on 11/29/11, from 1:16 pm to 1:49 pm revealed:
1. The 1st Floor Radiology Special Procedures Room failed to have sprinkler protection in the North Storage area behind the sliding glass partition.
2. The facility failed to install sprinkler heads at least 6 inches away from exam lights that obstructed sprinkler heads in ER Exam Rooms 2 and 3.
During an interview on 11-29-11 at the times of observations, Engineering A confirmed the lack of sprinkler protection and the obstructed sprinkler heads.

Actual NFPA Standard:
5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

Based on observation and interview, the facility failed to install the automatic sprinkler system to provide unobstructed coverage for all portions of the building in accordance with NFPA 13. This deficient practice affected all patients, visitors and staff that are in the area of those areas without sprinkler protection. The facility capacity is 173 and the census was 52.

Findings are:
Observation on 11/29/11, at 9:28 am revealed a fire alarm conduit installed less than 6 " away from two sprinkler heads in the 7th Floor North Storage Room.
In an interview conducted at the time of observation, (11/29/11, at 9:28 am), Maintenance D acknowledged the findings.

Actual NFPA Standard:
5-6.5.1.2
Sprinklers shall be arranged to comply with 5-5.5.2, Table 5-6.5.1.2, and Figure 5-6.5.1.2(a).

Based on observation, record review and interview, the facility failed to maintain and test a complete automatic sprinkler system with weekly, monthly and quarterly inspections and testing. All smoke compartments and all occupants could be affected by the deficient practice. At the time of the survey the census was 52.

Findings are:
1. Documentation review on 11/29/11 of the fire sprinkler reports revealed the sprinkler system had an annual inspection on 5/26/11. Noted on the report was " (fire pump) control valves for the jockey pump are not secured in the open position " . Interview with Engineering C on 11/29/11 at 10:35 am revealed the failure of this to be corrected.
2. Documentation review of the fire alarm inspection reports dated 3/23/11, 6/23/11, and 9/15/11 revealed 100% of the flow switches had not been tested. A partial count of the flow switches had been documented at each of the inspections. The last report for 100% flow switch testing was dated 12/7/10 by the fire alarm inspectors.
3. Interview with Engineering C on 11/29/11 at approximately 11:10 am revealed the flow switches tested by the Fire alarm company could not be verified as to which flow switches had been tested. In addition Engineering C stated that he conducted flow switch inspections on 11/10/10, 2/8/11, 5/12/11 and 8/11/11. Review of the fire alarm activation report revealed only the 8/11/11 test had been received at the central receiving.
4. No documentation of a five year obstruction testing could be provided for review.
Interview with Engineering C at this time confirmed the findings.
NFPA Standard: Requires sprinkler systems to be continuously maintained in proper operating condition and an inspection every quarter of a calendar year. 1998 NFPA 25, 2-2 and 2000 NFPA 101, 4.6.12.1



13879

Based on observation and interview, the facility failed to maintain the sprinkler system in accordance with the 1998 Edition of NFPA 25, by ensuring that sprinkler heads are installed as required. This deficient practice effected patients, staff and visitors on the 5th floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:54 am revealed the escutcheon in Patient Room 514 restroom was hanging from the ceiling.
During an interview on 11-29-11 at 9:54 am, Engineering B confirmed the findings.



27395

Observations on 11/29/11, from 9:24 am to 11/30/11, at 3:58 pm revealed:
1. In the North Stair Tower outside of the 9th Floor Mechanical Room, a sprinkler head had masking tape wrapped around it.
2. A sprinkler head in the 1st Floor Radiology Reading Room failed to have an escutcheon ring installed.
3. A sprinkler head in the 1st Floor Histology Conference Room failed to have an escutcheon ring installed.
4. A sprinkler head in the 1st Floor Old CP Waiting Room failed to have an escutcheon ring installed.
5. The Ground Level Social Services Office had a hole in the ceiling tile around the sprinkler head towards the back of the Room.
In an interview conducted at the times of observations, (11/29/11, from 9:24 am to 11/30/11, at 3:58 pm), Engineering C acknowledged the findings.

NFPA Standard:
Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. 1998 NFPA 25, 2-2.1.1

Based on observation and staff interview, the facility failed to keep a sprinkler head free of obstructions. This condition had the potential to interrupt the discharge pattern of the sprinkler head. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/28/11, at 2:02 pm revealed a Biodex Fall Protection Device was positioned within six inches of a sprinkler head. The facility failed to maintain the sprinkler head free of obstructions.
In an interview conducted at the time of observation, (11/28/11, at 2:02 pm) Engineering C acknowledged the obstruction to the sprinkler head.

Based on observation and staff interview, the facility failed to keep ceiling tiles in place in the suspended ceiling. This condition had the potential to allow heat to escape from around sprinkler heads and delay their reaction. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/28/11, at 2:28 pm revealed a missing ceiling tile and a broken tile in the Communication Room.
In an interview conducted at the time of observation, (11/28/11, at 2:28 pm), Engineering C acknowledged the findings.

Based on observation and staff interview, the facility failed to protect cooking equipment in accordance with NFPA, 96. This condition had the potential for fire spread quickly due to grease laden vapors emitted during cooking from unprotected cooking equipment. Facility census was 52 of 173.

Findings are:
Observation during the facility tour on 11/29/11, at 2:55 pm revealed:
1. A Panini Grill was used in the 1st Floor Cafe, and failed to be protected by a range hood suppression system. Grease was observed under the cabinet, above the grill and char was observed in the grill, due to a butter spray used with the grill.
2. The range hood in the 1st Floor Cafe failed to have filters that were not constructed of mesh material.
In an interview conducted at the time of observation, (11/29/11, at 2:55 pm), Engineering A acknowledged the findings.

Actual NFPA Standard:
Nebraska State Fire Marshal Official Interpretation 03-02.

NFPA 96, 6.2.3 Grease Filters.
6.2.3.1 Grease filters shall be listed and constructed of steel or listed equivalent material.
6.2.3.2 Grease filters shall be of rigid construction that will not distort or crush under normal operation, handling, and cleaning conditions.
6.2.3.3 Grease filters shall be arranged so that all exhaust air shall pass through the grease filters.

Based on observation and interview, the facility failed to maintain the means of egress free of all obstructions or impediments to full instant use in the case of fire or other emergency. This deficient practice affected patients, visitors and staff in the Ground Floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 2:15 pm and 3:11 pm revealed an approximate 56 foot long corridor filled with mobile soiled linen carts.

During an interview on 11-29-11 at 3:11 pm, Engineering B confirmed the soiled linen carts which filled the length of the 56 foot corridor and stated that housekeeping places them there for pick-up from a delivery service.

NFPA Standard:
Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. 2000 NFPA 101, 7.1.10.1

No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress from, or visibility thereof. 2000 NFPA 101, 7.1.10.2.1

Based on observation and interview, the facility failed to maintain the facility free from decorations of a highly flammable nature or provide the flame retardancy rating for decorations on corridor walls in the 5th floor Day Room. This deficient practice has the potential for smoke to migrate in the exiting corridors. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 at 9:45 am revealed a 36 inch by 25 inch fabric wall hanging in the 5th floor Day Room.

During an interview on 11-29-11 at 9:54 am, Engineering B confirmed the fabric wall hanging and stated that it had not been treated with any type of flame resistance.

NFPA Standard:
Combustible decorations shall be prohibited in any health care occupancy unless they are flame-retardant. Except that some combustible decorations, such as photographs and paintings, in such limited quantities that a hazard of fire development or spread is not present. 2000 NFPA 101, 18/19.7.5.4
Decorations and furnishings that do not meet the definition of interior finish shall be regulated by the provisions of Section 10.3. 2000 NFPA 101, 10.2.4.6
Where required by the applicable provisions of this Code, draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films. 2000 NFPA 101, 10.3.1

Based on observation and interview, the facility failed to maintain the facility free from highly flammable curtains or provide the flame retardant rating for the curtains in Patient Rooms 500, 501, 502, 504 and Day Room. This deficient practice has the potential for smoke and fire to migrate in the exiting corridors on the 5th floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 9:45 am and 10:15 am revealed:
1. Curtains on two of three windows in the 5th floor Day room failed to provide label for fire resistance.
2. Curtain on 5th floor Day room cabinets failed to provide label for fire resistance.
3. Curtain on the inside of Patient 500 door window failed to provide fire resistance label.
4. Curtain on the inside of Patient 501 door window failed to provide fire resistance label.
5. Curtain on the inside of Patient 502 door window failed to provide fire resistance label.
6. Curtain on the inside of Patient 504 door window failed to provide fire resistance label.

During an interview on 11-29-11at each time of observation, Engineering B confirmed the fabric curtains, and failed to provide documentation for the flame resistance.

NFPA Standard:
Draperies, curtains, and other similar loosely hanging furnishings and decorations shall be flame resistant as demonstrated by testing in accordance with NFPA 701. 2000 NFPA 101, 10.3.1

Based on observation and interview, the facility failed to have signage for medical gas cylinders in storage, which is in accordance with NFPA 99. This deficient practice affected all residents, staff and visitors on 5th, 4th and 2nd floors of the facility. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 10:19 am to 1:42 pm revealed:
5th Floor:
1. No oxygen signage outside Storage Room in the east corridor across from room 505.
4th Floor:
2. No oxygen signage outside Storage Room 4004, across from room 432.
2nd Floor:
3. No oxygen signage outside Storage Room 2215.
4. No oxygen signage outside Storage Room 2009.
During an interview on 11-29-11 at times of observations, Engineering B confirmed the lack of oxygen signage for storage of oxygen cylinders.

NFPA Standard:
Precautionary signs, readable from a distance of 5 feet, shall be conspicuously displayed wherever supplemental oxygen is in use, and in aisles and walkways leading to that area. They shall be attached to adjacent doorways or to building walls or be supported by other appropriate means. 1999 NFPA 99, 8-6.4.2

Based on observation and interview the facility failed to maintain the Level 1 Emergency Power Supply System in accordance with NFPA 110, Standard for Emergency and Standby Power Systems 1999 Edition by not providing the required fire rated separation of the Emergency Power Supply (EPS) and the Main normal electrical switchgear. Because the generators supply emergency power to the entire hospital facility this deficient practice has the potential to affect all residents, staff and visitors of the facility. The facility capacity is 173 and the census was 52.

Findings Are:
Observation on November 29, 2011 at 9:20am revealed that the doors between the generator room and the main electrical switchgear room were not installed in a fire-rated frame and did not have a fire-rating label installed on the doors themselves. The doors were also not self-closing and positive latching. This observation was confirmed in an interview with Engineering E at the above date and time.

Based on observation and interview the facility failed to maintain the Type I essential electrical system of the facility by having loads intermixed between the Life Safety Branch, The Critical Branch, and the Equipment System and by not having the required loads connected to proper branches of the Essential Electrical System. This deficient practice has the potential to affect all residents, staff and visitors of the facility by affecting the egress lighting and emergency systems of the facility. The facility capacity is 173 and the census was 52.

Findings Are:
1. Observation on November 29, 2011 at 8:50am revealed that there was the following life safety loads connected to the critical branch panel GCL1: #1 Generator enclosure panel with lights and receptacles. This observation was confirmed in an interview with Engineering E at the above date and time.
2. Observation on November 29, 2011 at 9:12am revealed that there was the following life safety loads connected to the equipment system panel GEL2: #1 Generator Battery Charger; #5 Emergency Lighting; #6 Ground Floor Emergency Lighting; #7 First floor emergency lighting; #18 Generator Battery Charger. This observation was confirmed in an interview with Engineering E at the above date and time.
3. Observation on November 29, 2011 at 9:32am revealed that there was the following critical branch loads connected to the equipment system panel GLENB: #8,10,12 Pharmacy Sub Panel; 19, 20, & 21 Lab outlets. This observation was confirmed in an interview with Engineering E at the above date and time.
4. Observation on November 29, 2011 at 9:42am revealed that there were the following critical loads connected to the equipment system panel EMGA: #8 Nurse Call and #10 Nurse Call. This observation was confirmed in an interview with Engineering E at the above date and time.
6. Observation on November 29, 2011 at 10:03am revealed that there was the following life safety load connected to the equipment system panel GHENA: #2 Exit Lights. This observation was confirmed in an interview with Engineering E at the above date and time.
7. Observation on November 29, 2011 at 10:09am revealed that there was the following life safety loads connected to the equipment system panel GLENA-SUB: #14 Canopy Lights, #16 Canopy Lights, and #18 Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
8. Observation on November 29, 2011 at 10:09am revealed that there was the following critical branch loads connected to the equipment system panel GLENA-SUB: #2 Lab, #4 Lab, #6 Lab, #8 Lab, #9 Nuclear Med, and #10 Nuclear Med. This observation was confirmed in an interview with Engineering E at the above date and time.
9. Observation on November 29, 2011 at 10:19am revealed that there was the following life safety loads connected to the equipment system panel DEC-1: #8 Night Lights and Exit Lights and #18 Server Room Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
10. Observation on November 29, 2011 at 10:28am revealed that there was the following Critical Loads connected to the normal power panel1L2: Nurse Call. This observation was confirmed in an interview with Engineering E at the above date and time.
11. Observation on November 29, 2011 at 10:31am revealed that there were the following non-critical loads connected to the critical branch panel EC1B: #19 TV outlet sleep room and #27 Sump pump. This observation was confirmed in an interview with Engineering E at the above date and time.
12. Observation on November 29, 2011 at 10:35am revealed that there was the following life safety loads connected to the equipment system panel 1HEL1: #1 1st floor exit lights, #2 1st floor emergency lights, #10 ground floor exit lights, #11 ground floor emergency lights, #13 emergency lights in OR 1 and OR 2, and #14 emergency lights sub-basement. This observation was confirmed in an interview with Engineering E at the above date and time.
13. Observation on November 29, 2011 at 10:46am revealed that there was the following critical branch loads connected to the life safety panel E1C: #26 Pyxis Rec Cardio Equipment, and #28 Nurse Call by Elevators. This observation was confirmed in an interview with Engineering E at the above date and time.
14. Observation on November 29, 2011 at 10:46am revealed that there was the following equipment system loads connected to the life safety panel E1C: #17 Chiller Heat Tape, #21 Rec, #22 Rec Doctors Dictation, #23 Rec, and #24 Johnson Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
15. Observation on November 29, 2011 at 10:49am revealed that there was the following non-life safety loads connected to the life safety panel E1B: #23 Cart Lift, #24 East Cart Lift, #26 West Cart Lift, and #28 Cat Lift Sump Pump. This observation was confirmed in an interview with Engineering E at the above date and time.
16. Observation on November 29, 2011 at 10:53am revealed that there were the following non-critical loads connected to the critical branch panel EC1D: #2 Auto Doors, #4 Auto Doors, #26 Auto Doors, #80 Johnson Controls, #82 Johnson Controls, and #84 Johnson Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
17. Observation on November 29, 2011 at 10:56am revealed that there were the following non-critical loads connected to the critical branch panel EC1F: #15 Auto Doors, #38 AHU#23 Equipment Power, #39 Penthouse heat tape, #40 Trane Control, and #41 Penthouse Lights. This observation was confirmed in an interview with Engineering E at the above date and time.
18. Observation on November 29, 2011 at 11:26am revealed that there was the following life safety loads connected to the equipment system panel 1LENA: #39 New Fire Alarm Panel. This observation was confirmed in an interview with Engineering E at the above date and time.
20. Observation on November 29, 2011 at 1:04pm revealed that there was the following non-life safety loads connected to the Bio-Med life safety panel: #1 North Rec Mikes Office, #5 North Outside Receptacle, and #7 North Outside Receptacle. This observation was confirmed in an interview with Engineering E at the above date and time.
21. Observation on November 29, 2011 at 1:10pm revealed that there was the following life safety loads connected to the equipment system panel EMGB: #19 New Fire Alarm Panel. This observation was confirmed in an interview with Engineering E at the above date and time.
22. Observation on November 29, 2011 at 1:12pm revealed that there was the following non-life safety loads connected to the life safety panel EGB: #1 Elevator pit alarm, #3 elevator pit, #5 time clock, #7 SW Sign, #9 Receptacle Kronos Home health, #12 Johnson Controls, #16 Elevator sump pump, and #18 Elevator pit light and receptacle. This observation was confirmed in an interview with Engineering E at the above date and time.
23. Observation on November 29, 2011 at 1:31pm revealed that there was the following non-life safety loads connected to the life safety panel 2LL1: #7 2nd Floor HUGS Power. This observation was confirmed in an interview with Engineering E at the above date and time.
24. Observation on November 29, 2011 at 1:33pm revealed that there were the following non-critical loads connected to the critical branch panel 2CL1: Johnson Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
25. Observation on November 29, 2011 at 1:49pm revealed that there were the following life safety loads connected to the equipment system panel GEL1: #32,34 Telephone room panel, #36 Hospital Paging Cabinet, #41 Fire Alarm and #42 Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
26. Observation on November 29, 2011 at 1:52pm revealed that there was the following life safety loads connected to the phone room equipment system panel: #5 Plug Mold North, #6 Outlet above east phone board, #7 Plugmold West, #9 South wall raised receptacle left, and #11 south wall raised receptacle right. This observation was confirmed in an interview with Engineering E at the above date and time.
27. Observation on November 29, 2011 at 2:07pm revealed that there was the following life safety loads connected to the critical branch panel 3EL1: #18 Tel Com Rm Fire alarm panel. This observation was confirmed in an interview with Engineering E at the above date and time.
28. Observation on November 29, 2011 at 2:11pm revealed that there was the following life safety loads connected to the critical branch panel 3HEL1: #1 Emergency lights, #3 Exit Lights, #6 Emergency Lights, and #9 Emergency and exit lights south stair tower. This observation was confirmed in an interview with Engineering E at the above date and time.
29. Observation on November 29, 2011 at 2:14pm revealed that there were the following non-critical loads connected to the critical branch panel 3EL2: #42 Security Door. This observation was confirmed in an interview with Engineering E at the above date and time.
30. Observation on November 29, 2011 at: 2:20pm revealed that there were the following non-critical loads connected to the critical branch panel 4CL1: #18 Trane Power. This observation was confirmed in an interview with Engineering E at the above date and time.
31. Observation on November 29, 2011 at 2:39pm revealed that there was the following life safety loads connected to the critical branch panel ELP7: #14 Fire Alarm, and #26 Emergency lights 7th Floor. This observation was confirmed in an interview with Engineering E at the above date and time.
32. Observation on November 29, 2011 at 2:39pm revealed that there were the following non-critical loads connected to the critical branch panel ELP7: #13 Door Locks, and #16 Trane Controls. This observation was confirmed in an interview with Engineering E at the above date and time.
33. Observation on November 29, 2011 at 2:55pm revealed that there was the following life safety loads connected to the equipment system panel 9th floor EM panel: #2 Elevator 1 Cab lights. #4 Elevator 2 Cab Lights, #11 Elevator 4 Cab Lights, and #13 Elevator 3 Cab Lights. This observation was confirmed in an interview with Engineering E at the above date and time.
34. Observation on November 29, 2011 at 3:10pm revealed that there was the following life safety load connected to the equipment system panel 9EL1: #5 Elevator Shaft Damper Motor. This observation was confirmed in an interview with Engineering E at the above date and time.
35. Observation on November 29, 2011 at 4:39pm revealed that there was the following life safety load connected to the normal panel GL5: #10 Fire Alarm. This observation was confirmed in an interview with Engineering E at the above date and time.
36. Observation on November 29, 2011 at 4:42pm revealed that there was the following equipment system loads connected to the normal power panel GHP2: Kitchen Exhaust hoods. This observation was confirmed in an interview with Engineering E at the above date and time.
37. Observation on November 29, 2011 at 4:48pm revealed that there was the following life safety load connected to the normal panel GL6: #43 Fire Alarm this room. This observation was confirmed in an interview with Engineering E at the above date and time.
38. Observation on November 29, 2011 at 4:48pm revealed that there was the following equipment system load connected to the normal panel GL6: #37 and #46 Hood Exhaust fan and controls. This observation was confirmed in an interview with Engineering E at the above date and time.
39. Observation on November 29, 2011 at 4:56pm revealed that there was the following life safety loads connected to the generator critical branch panel: #1 Generator room lights, #3 Generator Room Receptacles, #7 Generator Battery Charger, #13 Inside Receptacle and #16 Emergency light. This observation was confirmed in an interview with Engineering E at the above date and time.
40. Observation on November 29, 2011 at 4:56pm revealed that there was the following non-critical loads connected to the generator critical branch panel: #2,4 Jacket Heater, #5 Damper Motor, #6,10 Room Heater, #9,11 Tank Heater, #10,12 Space Heater, and #14 Outside Receptacle. This observation was confirmed in an interview with Engineering E at the above date and time.

NFPA 70, 1999ed.
517.30 Essential Electrical Systems for Hospitals.
(A) Applicability. The requirements of Part III, 517.30 through 517.35, shall apply to hospitals where an essential electrical system is required.
(B) General.
(1) Separate Systems. Essential electrical systems for hospitals shall be comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for life safety and effective hospital operation during the time the normal electrical service is interrupted for any reason. These two systems shall be the emergency system and the equipment system.
(2) Emergency Systems. The emergency system shall be limited to circuits essential to life safety and critical patient care. These are designated the life safety branch and the critical branch.
(3) Equipment System. The equipment system shall supply major electrical equipment necessary for patient care and basic hospital operation.
(4) Transfer Switches. The number of transfer switches to be used shall be based on reliability, design, and load considerations. Each branch of the emergency system and each equipment system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA.
(5) Other Loads. Loads served by the generating equipment not specifically named in Article 517 shall be served by their own transfer switches such that these loads:
(1) Shall not be transferred if the transfer will overload the generating equipment.
(2) Shall be automatically shed upon generating equipment overloading.
(6) Contiguous Facilities. Hospital power sources and alternate power sources shall be permitted to serve the essential electrical systems of contiguous or same site facilities. [NFPA 99, 3.4.2.2.1, 12.3.3.2]
(C) Wiring Requirements.
(1) Separation from Other Circuits. The life safety branch and critical branch of the emergency system shall be kept entirely independent of all other wiring and equipment and shall not enter the same raceways, boxes, or cabinets with each other or other wiring.
Wiring of the life safety branch and the critical branch shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits not part of the branch where such wiring is as follows:
(1) In transfer equipment enclosures, or
(2) In exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(3) In a common junction box attached to exit or emergency luminaires (lighting fixtures) supplied from two sources, or
(4) For two or more emergency circuits supplied from the same branch
The wiring of the equipment system shall be permitted to occupy the same raceways, boxes, or cabinets of other circuits that are not part of the emergency system.
(2) Isolated Power Systems. Where isolated power systems are installed in any of the areas in 517.33(A)(1) and (A)(2), each system shall be supplied by an individual circuit serving no other load.
(3) Mechanical Protection of the Emergency System. The wiring of the emergency system of a hospital shall be mechanically protected by installation in nonflexible metal raceways, or shall be wired with Type MI cable.
Exception No. 1: Flexible power cords of appliances, or other utilization equipment, connected to the emergency system shall not be required to be enclosed in raceways.
Exception No. 2: Secondary circuits of transformer-powered communications or signaling systems shall not be required to be enclosed in raceways unless otherwise specified by Chapters 7 or 8.
Exception No. 3: Schedule 80 rigid nonmetallic conduit shall be permitted if the branch circuits do not serve patient care areas and it is not prohibited elsewhere in this Code.
Exception No. 4: Where encased in not less than 50 mm (2 in.) of concrete, Schedule 40 rigid nonmetallic conduit or electrical nonmetallic tubing shall be permitted if the branch circuits do not serve patient care areas.
Exception No. 5: Flexible metal raceways and cable assemblies shall be permitted to be used in listed prefabricated medical headwalls, listed office furnishings, or where necessary for flexible connection to equipment.
(D) Capacity of Systems. The essential electrical system shall have adequate capacity to meet the demand for the operation of all functions and equipment to be served by each system and branch.
Feeders shall be sized in accordance with Articles 215 and 220. The generator set(s) shall have sufficient capacity and proper rating to meet the demand produced by the load of the essential electrical system(s) at any given time.
Demand calculations for sizing of the generator set(s) shall be based on the following:
(1) Prudent demand factors and historical data, or
(2) Connected load, or
(3) Feeder calculation procedures described in Article 220, or
(4) Any combination of the above
The sizing requirements in 700.5 and 701.6 shall not apply to hospital generator set(s).
(E) Receptacle Identification. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. [NFPA 99, 3.4.2.2.4(b)2]
517.31 Emergency System.
Those functions of patient care depending on lighting or appliances that are connected to the emergency system shall be divided into two mandatory branches: the life safety branch and the critical branch, described in 517.32 and 517.33. The branches of the emergency system shall be installed and connected to the alternate power source so that all functions specified herein for the emergency system shall be automatically restored to operation within 10 seconds after interruption of the normal source. [NFPA 99, 3.4.2.2.2(a), 3.5.2.2.2]
517.32 Life Safety Branch.
No function other than those listed in 517.32(A) through (G) shall be connected to the life safety branch. The life safety branch of the emergency system shall supply power for the following lighting, receptacles, and equipment.
(A) Illumination of Means of Egress. Illumination of means of egress, such as lighting required for corridors, passageways, stairways, and landings at exit doors, and all necessary ways of approach to exits. Switching arrangements to transfer patient corridor lighting in hospitals from general illumination circuits to night illumination circuits shall be permitted, provided only one of two circuits can be selected and both circuits cannot be extinguished at the same time.
(B) Exit Signs. Exit signs and exit directional signs.
(C) Alarm and Alerting Systems. Alarm and alerting systems including the following:
(1) Fire alarms
(2) Alarms required for systems used for the piping of nonflammable medical gases
(D) Communications Systems. Hospital communications systems, where used for issuing instructions during emergency conditions.
(E) Generator Set Location. Task illumination battery charger for emergency battery-powered lighting unit(s) and selected receptacles at the generator set location.
(F) Elevators. Elevator cab lighting, control, communications, and signal systems.
(G) Automatic Doors. Automatically operated doors used for building egress. [NFPA 99, 3.4.2.2.2(b)]
517.33 Critical Branch.
(A) Task Illumination and Selected Receptacles. The critical branch of the emergency system shall supply power for task illumination, fixed equipment, selected receptacles, and special power circuits serving the following areas and functions related to patient care:
(1) Critical care areas that utilize anesthetizing gases - task illumination, selected receptacles, and fixed equipment
(2) The isolated power systems in special environments
(3) Patient care areas - task illumination and selected receptacles in the following:
a. Infant nurseries
b. Medication preparation areas
c. Pharmacy dispensing areas
d. Selected acute nursing areas
e. Psychiatric bed areas (omit receptacles)
f. Ward treatment rooms
g. Nurses ' stations (unless adequately lighted by corridor luminaires)
(4) Additional specialized patient care task illumination and receptacles, where needed
(5) Nurse call systems
(6) Blood, bone, and tissue banks
(7) Telephone equipment rooms and closets
(8) Task illumination, selected receptacles, and selected power circuits for the following:
a. General care beds (at least one duplex receptacle per patient bedroom)
b. Angiographic labs
c. Cardiac catheterization labs
d. Coronary care units
e. Hemodialysis rooms or areas
f. Emergency room treatment areas (selected)
g. Human physiology labs
h. Intensive care units
i. Postoperative recovery rooms (selected)
(9) Additional task illumination, receptacles, and selected power circuits needed for effective hospital operation. Single-phase fractional horsepower motors shall be permitted to be connected to the critical branch. [NFPA 99, 3.4.2.2.2(c)]
(B) Subdivision of the Critical Branch. It shall be permitted to subdivide the critical branch into two or more branches.
517.34 Equipment System Connection to Alternate Power Source.
The equipment system shall be installed and connected to the alternate power source such that the equipment described in 517.34(A) is automatically restored to operation at appropriate time-lag intervals following the energizing of the emergency system. Its arrangement shall also provide for the subsequent connection of equipment described in 517.34(B). [NFPA 99, 3.4.2.2.3(b)]
Exception: For essential electrical systems under 150 kVA, deletion of the time-lag intervals feature for delayed automatic connection to the equipment system shall be permitted.
(A) Equipment for Delayed Automatic Connection. The following equipment shall be arranged for delayed automatic connection to the alternate power source.
(1) Central suction systems serving medical and surgical functions, including controls. Such suction systems shall be permitted on the critical branch.
(2) Sump pumps and other equipment required to operate for the safety of major apparatus, including associated control systems and alarms.
(3) Compressed air systems serving medical and surgical functions, including controls. Such air systems shall be permitted on the critical branch.
(4) Smoke control and stair pressurization systems, or both.
(5) Kitchen hood supply or exhaust systems, or both, if required to operate during a fire in or under the hood. [NFPA 99, 3.4.2.2.3(d)]
Exception: Sequential delayed automatic connection to the alternate power source to prevent overloading the generator shall be permitted where engineering studies indicate it is necessary.
(B) Equipment for Delayed Automatic or Manual Connection. The following equipment shall be arranged for either delayed automatic or manual connection to the alternate power source:
(1) Heating equipment to provide heating for operating, delivery, labor, recovery, intensive care, coronary care, nurseries, infection/isolation rooms, emergency treatment spaces, and general patient rooms and pressure maintenance (jockey or make-up) pump(s) for water-based fire protection systems.
Exception: Heating of general patient rooms and infection/isolation rooms during disruption of the normal source shall not be required under any of the following conditions:
(a) The outside design temperature is higher than -6.7?C (20?F).
(b) The outside design temperature is lower than -6.7?C (20?F), and where a selected room(s) is provided for the needs of all confined patients, only such room(s) need be heated.
(c) The facility is served by a dual source of normal power.
(2) An elevator(s) selected to provide service to patient, surgical, obstetrical, and ground floors during interruption of normal power. In instances where interruption of normal power would result in other elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of patients or other persons who may be confined between floors.
(3) Supply, return, and exhaust ventilating systems for airborne infectious/isolation rooms, protective environment rooms, exhaust fans for laboratory fume hoods, nuclear medicine areas where radioactive material is used, ethylene oxide evacuation and anesthesia evacuation. Where delayed automatic connection is not appropriate, such ventilation systems shall be permitted to be placed on the critical branch. [NFPA 99, 3.4.2.2.3(e)(4)]
(4) Hyperbaric facilities.
(5) Hypobaric facilities.
(6) Automatically operated doors.
(7) Minimal electrically heated autoclaving equipment shall be permitted to be arranged for either automatic or manual connection to the alternate source.
(8) Controls for equipment listed in 517.34.
(9) Other selected equipment shall be permitted to be served by the equipment system. [NFPA 99, 3.4.2.2.3(e)]

Based on staff interview and observation, the facility failed to ensure all electrical is installed in accordance with National Fire Protection Association 70 (electrical code). This practice affected all patients, visitors and staff on the 5th floor and Ground Floor. The facility capacity is 173 and the census was 52.

Findings are:
Observations on 11-29-11 between 9:40 am to 2:50 pm revealed:
5th Floor:
1. Power strip used as permanent wiring for a Television, DVD, VCR and WII in the 5th floor Day Hall.
2. Power strip used as permanent wiring for the fish tank and equipment in the 5th floor Day Hall.
Ground Floor:
3. Storage of items in front of the panel box in Bio-Med room.
4. Refrigerator plugged into a power strip under the desk of the Store Room Clerk office area in Purchasing Room.
During an interview on 11-29-11 at each time of observation, Engineering B confirmed the findings.



20404

Based on observation and interview the facility failed to maintain the electrical system of the facility in accordance with NFPA 70, National Electrical Code 1999ed. by not having complete and accurate circuit directories, by not maintaining panels such that they are dead front with no exposed live buss, by not having signage to indicate the locations of emergency power systems, and by not having the required working clearances in front of electrical equipment that requires servicing. These deficient practices are located throughout the facility and put the entire electrical system at risk, pose a greater fire hazard to the facility and leave persons exposed to possible electric shock hazards. The facility capacity is 173 and the census was 52.

Findings Are:
1. Observation on November 29, 2011 at 9:25am revealed that the motor control center in the west equipment room was not labeled or identified. This observation was confirmed in an interview with Engineering E at the above date and time.
2. Observation on November 29, 2011 at 10:09am revealed that there was no signage installed at any of the service entrance locations to indicate the types and locations of on-site emergency power sources. This observation was confirmed in an interview with Engineering E at the above date and time.
3. Observation on November 29, 2011 at 9:42am revealed that there was no panel schedule installed in or on the equipment system panel EMGA. This observation was confirmed in an interview with Engineering E at the above date and time.
4. Observation on November 29, 2011 at 10:09am revealed that the equipment system motor control center N2 was not labeled or identified. This observation was confirmed in an interview with Engineering E at the above date and time.
5. Observation on November 29, 2011 at 10:38am revealed that the circuit directory for the equipment system panel EM1A was not complete and was not identified at the panel ahead of it EMGA. This observation was confirmed in an interview with Engineering E at the above date and time.
6. Observation on November 29, 2011 at 11:09am revealed that the circuit directory for the equipment system panel EM1B was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
7. Observation on November 29, 2011 at 11:39am revealed that the equipment system panel GEL3 circuit directory was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
8. Observation on November 29, 2011 at 1:04pm revealed that the life safety panel bio-med was not dead front and had exposed live buss. This observation was confirmed in an interview with Engineering E at the above date and time.
9. Observation on November 29, 2011 at 1:04pm revealed that the life safety panel bio-med circuit directory was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
10. Observation on November 29, 2011 at 1:04pm revealed that the life safety panel bio-med did not have the required working clearances in front of the panel to allow ready access to the panel in an emergency. This observation was confirmed in an interview with Engineering E at the above date and time.
11. Observation on November 29, 2011 at 1:10pm revealed that there was not the required working clearances in front of the equipment system panel EMGB and the normal panel LGC. This observation was confirmed in an interview with Engineering E at the above date and time.
12. Observation on November 29, 2011 at 2:09pm revealed that the circuit directory for the critical branch panel 3EL1/S was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
13. Observation on November 29, 2011 at 2:11pm revealed that the circuit directory for the critical branch panel 3HEL1 was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
14. Observation on November 29, 2011 at 2:40pm revealed that the circuit directory for the critical branch panel ELP7 was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
15. Observation on November 29, 2011 at 2:54pm revealed that the circuit directory for the equipment system panel 9HEP was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.
16. Observation on November 29, 2011 at 4:31pm revealed that the life safety panel on the 7th floor was not identified and there was no circuit directory installed in or on the panel. This observation was confirmed in an interview with Engineering E at the above date and time.
17. Observation on November 29, 2011 at 4:31pm revealed that the life safety panel on the 7th floor was not dead front and had exposed live buss. This observation was confirmed in an interview with Engineering E at the above date and time.
18. Observation on November 29, 2011 at 4:48pm revealed that the circuit directory for the normal panel GL6 was not complete. This observation was confirmed in an interview with Engineering E at the above date and time.

NFPA 70, 1999ed. 110.22
Identification of Disconnecting means. Each disconnecting means required by this code for motors and appliances, and each service, feeder, or branch circuit at the point where it originates, shall be legibly marked to indicate its purpose unless located and arranged so the purpose is evident. The marking shall be of sufficient durability to withstand the environment involved.

NFPA 70, 1999ed.
110.26 Spaces About Electrical Equipment.
Sufficient access and working space shall be provided and maintained about all electric equipment to permit ready and safe operation and maintenance of such equipment. Enclosures housing electrical apparatus that are controlled by lock and key shall be considered accessible to qualified persons.
(A) Working Space. Working space for equipment operating at 600 volts, nominal, or less to ground and likely to require examination, adjustment, servicing, or maintenance while energized shall comply with the dimensions of 110.26(A)(1), (2), and (3) or as required or permitted elsewhere in this Code.
(1) Depth of Working Space. The depth of the working space in the direction of live parts shall not be less than that specified in Table 110.26(A)(1) unless the requirements of 110.26(A)(1)(a), (b), or (c) are met. Distances shall be measured from the exposed live parts or from the enclosure or opening if the live parts are enclosed.
Table 110.26(A)(1) Working Spaces

Nominal Voltage to Ground Minimum Clear Distance
Condition 1 Condition 2 Condition 3
0-150 900 mm (3 ft) 900 mm (3 ft) 900 mm (3 ft)
151-600 900 mm (3 ft) 1 m (3? ft) 1.2 m (4 ft)

Note: Where the conditions are as follows:
Condition 1 - Exposed live parts on one side and no live or grounded parts on the other side of the working space, or exposed live parts on both sides effectively guarded by suitable wood or other insulating materials. Insulated wire or insulated busbars operating at not over 300 volts to ground shall not be considered live parts.
Condition 2 - Exposed live parts on one side and grounded parts on the other side. Concrete, brick, or tile walls shall be considered as grounded.
Condition 3 - Exposed live parts on both sides of the work space (not guarded as provided in Condition 1) with the operator between.

(a) Dead-Front Assemblies. Working space shall not be required in the back or sides of assemblies, such as dead-front switchboards or motor control centers, where all connections and all renewable or adjustable parts, such as fuses or switches, are accessible from locations other than the back or sides. Where rear access is required to work on nonelectrical parts on the back of enclosed equipment, a minimum horizontal working space of 762 mm (30 in.) shall be provided.
(b) Low Voltage. By special permission, smaller working spaces shall be permitted where all uninsulated parts operate at not greater than 30 volts rms, 42 volts peak, or 60 volts dc.
(c) Existing Buildings. In existing buildings where electrical equipment is being replaced, Condition 2 working clearance shall be permitted between dead-front switchboards, panelboards, or motor control centers located across the aisle from each other where conditions of maintenance and supervision ensure that written procedures have been adopted to prohibit equipment on both sides of the aisle from being open at the same time and qualified persons who are authorized will service the installation.
(2) Width of Working Space. The width of the working space in front of the electric equipment shall be the width of the equipment or 750 mm (30 in.), whichever is greater. In all cases, the work space shall permit at least a 90 degree opening of equipment doors or hinged panels.
(3) Height of Working Space. The work space shall be clear and extend from the grade, floor, or platform to the height required by 110.26(E). Within the height requirements of this section, other equipment that is associated with the electrical installation and is located above or below the electrical equipment shall be permitted to extend not more than 150 mm (6 in.) beyond the front of the electrical equipment.
(B) Clear Spaces. Working space required by this section shall not be used for storage. When normally enclosed live parts are exposed for inspection or servicing, the working space, if in a passageway or general open space, shall be suitably guarded.
(C) Entrance to Working Space.
(1) Minimum Required. At least one entrance of sufficient area shall be provided to give access to working space about electrical equipment.
(2) Large Equipment. For equipment rated 1200 amperes or more and over 1.8 m (6 ft) wide that contains overcurrent devices, switching devices, or control devices, there shall be one entrance to the required working space not less than 610 mm (24 in.) wide and 2.0 m (6? ft) high at each end of the working space. Where the entrance has a personnel door(s), the door(s) shall open in the direction of egress and be equipped with panic bars, pressure plates, or other devices that are normally latched but open under simple pressure.
A single entrance to the required working space shall be permitted where either of the conditions in 110.26(C)(2)(a) or (b) is met.
(a) Unobstructed Exit. Where the location permits a continuous and unobstructed way of exit travel, a single entrance to the working space shall be permitted.
(b) Extra Working Space. Where the depth of the working space is twice that required by 110.26(A)(1), a single entrance shall be permitted. It shall be located so that the distance from the equipment to the nearest edge of the entrance is not less than the minimum clear distance specified in Table 110.26(A)(1) for equipment operating at that voltage and in that condition.
(D) Illumination. Illumination shall be provided for all working spaces about service equipment, switchboards, panelboards, or motor control centers installed indoors. Additional lighting outlets shall not be required where the work space is illuminated by an adjacent light source or as permitted by 210.70(A)(1), Exception No. 1, for switched receptacles. In electrical equipment rooms, the illumination shall not be controlled by automatic means only.
(E) Headroom. The minimum headroom of working spaces about service equipment, switchboards, panelboards, or motor control centers shall be 2.0 m (6? ft). Where the electrical equipment exceeds 2.0 m (6? ft) in height, the minimum headroom shall not be less than the height of the equipment.
Exception: In existing dwelling units, service equipment or panelboards that do not exceed 200 amperes shall be permitted in spaces where the headroom is less than 2.0 m (6? ft).
(F) Dedicated Equipment Space. All switchboards, panelboards, distribution boards, and motor control centers shall be located in dedicated spaces and protected from damage.
Exception: Control equipment that by its very nature or because of other rules of the Code must be adjacent to or within sight of its operating machinery shall be permitted in those locations.
(1) Indoor. Indoor installations shall comply with 110.26(F)(1)(a) through (d).
(a) Dedicated Electrical Space. The space equal to the width and depth of the equipment and extending from the floor to a height of 1.8 m (6 ft) above the equipment or to the structural ceiling, whichever is lower, shall be dedicated to the electrical installation. No piping, ducts, leak protection apparatus, or other equipment foreign to the electrical installation shall be located in this zone.
Exception: Suspended ceilings with removable panels shall be permitted within the 1.8-m (6-ft) zone.
(b) Foreign Systems. The area above the dedicated space required by 110.26(F)(1)(a) shall be permitted to contain foreign systems, provided protection is installed to avoid damage to the electrical equipment from condensation, leaks, or breaks in such foreign systems.
(c) Sprinkler Protection. Sprinkler protection shall be permitted for the dedicated space where the piping complies with this section.
(d) Suspended Ceilings. A dropped, suspended, or similar ceiling that does not add strength to the building structure shall not be considered a structural ceiling.
(2) Outdoor. Outdoor electrical equipment shall be installed in suitable enclosures and shall be protected from accidental contact by unauthorized personnel, or by vehicular traffic, or by accidental spillage or leakage from piping systems. The working clearance space shall include the zone described in 110.26(A). No architectural appurtenance or other equipment shall be located in this zone.

NFPA 70, 1999ed. 384-18. Enclosure.
Panelboards shall be mounted in cabinets, cutout boxes, or enclosures designed for the purpose and shall be dead front.

NFPA 70, 1999ed. 700-8. Signs.
(a) Emergency Sources. A sign shall be placed at the service entrance equipment indicating type and location of on-site emergency power sources.



27395

Observations during the facility tour on 11/28/11, from 3:33 pm to 11/30/11, at 10:41 am revealed:
1. The facility failed to close the open junction box above ceiling on 6th Floor at the can light outside of Room 618.
2. The facility failed to close the open junction box above ceiling on 6th Floor above the North Stair Tower Door.
3. The facility failed to close the open junction box in the 3rd Floor Biomed Northwest Storage Room.
4. On the 1st Floor in the Mamography Room, the electrical receptacles built into the Mamo Desk were exposed and laying on the floor.
5. The facility failed to close two open junction boxes in the 1st Floor MRI Equipment Room.
6. The facility failed to close the open junction box above the double doors north of Elevator 4 on the 1st Floor.
7. On the 1st Floor above the time clock on the west side of the Lab, open blanks were observed in a junction box above ceiling.
In an interview conducted at the times of observations, (11/28/11, from 3:33 pm to 11/30/11, at 10:41 am), Engineering C acknowledged the findings.

NFPA Standard:
Flexible cords and cables shall not be used: as a substitute for the fixed wiring of a structure; run through holes in walls, ceilings or floors, doorways or windows; attached to building surfaces; or concealed behind building walls, ceilings, or floors. 1999 NFPA 70, article 400-8, 1999 NFPA 110, 6.4.1 and 6.4.2

Sufficient access and working space shall be provided and maintained about all electrical equipment to permit ready and safe operation and maintenance of such equipment. 2002 NFPA 70, 110.26

Based on observation and staff interview, the facility failed to use electrical equipment in accordance with the National Fire Protection Association, 70. This condition had the potential to cause an electrical shock. Facility census was 52 of 173.

Findings are:

Observation during the facility tour on 11/28/11 at 1:58 pm revealed a missing cover plate from a wall outlet in the PFT Room.
In an interview conducted at the time of observation, (11/28/11 at 1:58 pm), Engineering C acknowledged the findings.